AGENDA - San Francisco Health Plan · • A new QIC Committee member was announced - Dr. Ana...

Quality Improvement, Physician Advisory, Peer Review, and Credentialing Committees Meeting

Thursday, February 11, 2016

7:30 – 9:00 AM 50 Beale Street, 13th Floor

Dial in Information:

Dial +1 (408) 650-3123 Access Code: 252-261-949

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AGENDA

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Quality Improvement Committee: Open Session Tab Time Topic Objective Assigned

1 7:30 Follow Up Items (5 min) Update Dr. Glauber

QIC: quorum: 5 QIC members, 3 physicians, including committee chair • Public Comments/Questions • Review Follow Up Items (p. 3)

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2 7:35 Consent Calendar (5 min) Update / Vote Dr. Glauber

• Review of Minutes – December 10, 2015 (p. 4) • Health Services Update (p. 30) • Membership Report (p. 35) • Q3 2015 Appeals Report (p .44) • Update of Pharmacy & Therapeutics

Committee Membership (p. 51) & Minutes (p. 52)

• Policies & Procedures o Summary of Changes (p. 61) o QI-01: Quality Improvement Committee

(p. 62) o QI-11: Physician Advisory Peer Review

Credentialing Committee (p. 65) o Pharm-08: Pharmacy Formulary, Prior

Authorization Criteria, and Policy Annual Review (p. 68)

o Pharm-09: Pharmacy Formulary, Prior Authorization Criteria, and Policy Annual Review (p. 70)

• UM Committee Minutes o December 2015 (p. 73) o January 2016 (p. 81)

Vote

3 7:40 Policies and Procedures (10 min)

• CARE-04: Complex Medical Case Management (p. 88)

Vote F. Donald

4 7:50 Quality Monitoring (50 min)

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Quality Improvement, Physician Advisory, Peer Review, and Credentialing Committees Meeting

Thursday, February 11, 2016

7:30 – 9:00 AM 50 Beale Street, 13th Floor

Dial in Information:

Dial +1 (408) 650-3123 Access Code: 252-261-949

Audio PIN: press # https://global.gotomeeting.com/join/252261949

AGENDA

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• Q3 2015 Grievances – 5 min. (p. 104) • FSR 2015 Results – 5 min. (p. 115) • SFHN & UCSF DMG Audit Results (p.117 – 10

min. • QI DMG Audit Summary Revisions (p. 119) – 2

min. • Introduction to Telemedicine (p. 123) – 20 min.

Vote Vote Vote Update

N. Ylagan A. Wolf O.Bigler J. Glauber

6 8:30 PAC

NEXT MEETING THURSDAY, April 14th

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QIC Meeting Date Follow Up Item Owner Complete By Status Comments

January 2015Submit to committee the infant mortality rate between African American and

CaucasiansS. Weis 2/12/15 Completed Submitted to the committee on 2/12/15

February 2015Can SFHP's pharmacy dept be able to approve non-formulary medications when

the member is in the ED?N. Ylagan 3/4/15 Completed

There is a P&P that describes this process - Pharm-07. The pharmacy will be able to process one prescription of up to a 5 day supply per year without a prior authorization. The following are covered in the policy: 1. The following medications in the chronic pain drug class: fentanyl patch(Duragesic®)**, morphine sulfate SR (Kadian®), oxycodone SR(Oxycontin®), oxymorphone SR (Opana®)2. All medications in the immunosuppressant drug class3. All medications in the seizure drug class4. All medications for treatment of Hepatitis B5. All antibiotics** 6 days supply is allowed for fentanyl

February 2015For investigations that involve PQIs, can SFHP turnaround times match SFGH's

turnaround times?J. Soo 6/11/15 Completed

SFHP contacted SFGH's Director of Quality Management but didn't a response.

April 2015 Where can Healthy Workers go for a 24/7 pharmacy if need be? N. Ylagan 6/11/15 CompletedWalgreens: 1189 Potrero Avenue(415) 647-0368; Information added to the website

April 2015 Review SFHP's Customer Service standards for member wait time on the phone. A. Sharma 9/30/15 Completed The industry standard is 10 minutes.

April 2015 Review process to verify the phone numbers of providers in QNXT for accuracy A. Sharma 9/30/15 Completed

Individual providers are not required to have phone numbers but clinical are. This allows for providers to work at multiple clinics. Currently, Provider Network Operations is working on a provider data improvement project.

April 2015 Create a basic access standard tools for providers A. Sharma 9/30/15 CompletedBy the December QIC, a timely access regulation dashboard presented to QIC and a one pager of information of all the timely access regulations

June 2015 Additional Information about how many members Beacon has N. Ylagan 8/13/15 Completed See attachments in the packet

June 2015 Status of DHCS approval of the ambulatory blood pressure cuff J. Glauber 10/8/15 CompletedThe final DHCS 2015 report was given to SFHP on 8/26/15. SFHP will be submitted the Corrective Action Plans (CAP) by 9/30/15.

October 2015 How many medical groups have a service recovery policy? A. Sharma 12/2/15 CompletedCurrently, there are no medical groups or clinics have an official service recovery program. However, all clinics have a way of resolving patients problems internally.

December 2015 Do the adult immunizations as a covered benefit apply to Healthy Workers? L. Ghotbi/D. Tan 2/8/16 Completed Only applies as a Medi-Cal benefit.

Quality Improvement Committee Follow Up List

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Quality Improvement Committee Minutes Date: December 10th, 2015 Meeting Place: San Francisco Health Plan, 50 Beale Street 12th Floor, San Francisco, CA 94105 Meeting Time: 7:30-9:00 am Present: Irene Conway, Edward Evans, Jeffery Critchfield, MD; Joseph Woo, MD; Todd May, MD; Daniel Chan, MD;

Richard Zercher, MD; Kenneth Tai, MD Staff Present: James Glauber, MD; Jim Soos, Nicole A. Ylagan, Sari Weis, Jess Strange, Jessica Warren, Collin Elane, Sean

Dongre, Odalis Bigler, Maika Hefflefinger, Laura Grossman,

Topic Discussion [including

Identification of Quality Issue]

Follow-up [if Quality Issue identified, Include Corrective Action]

Resolution, or Closed Date [for Quality Issue, add plan

for Tracking after Resolution]

Call to Order • Meeting was called to order at 7:28 am • A new QIC Committee member was

announced - Dr. Ana Valdes, the Chief Health Officer at Health Right 360. She is replacing Dr. Richard Zercher who’s been with us for several years and retiring towards the end of the month. Thank you to Dr. Zercher’s contributions at SFHP.

• There were no public comments.

• No follow up needed • n/a

Follow Up Items

• DHCS Corrective Action Plan (CAP) Update: o SFHP has submitted its Corrective

Action Plan (CAP) to the state. We have addressed approximately 55 findings, stating how we will correct

• No follow up needed • n/a

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those findings. The state has reviewed and provisionally closed most of SFHP’s CAP’s. The remainder is expected to be closed by Dec. 15. Closing a finding means that they have accepted our proposed Correct Action Plan (CAP) to address and correct it. In the subsequent audit next year, the state will look for evidence that all CAP’s have been executed and completed.

o In previous meetings we have presented both our HEDIS results and CAHPS member satisfaction results for 2014. DHCS also puts out a quality scorecard, comparing the 22 Medi-Cal plans in California to different health plans in California. SFHP reports on 27 different HEDIS measures which are combined to attain an aggregated quality score to compare SFHP to other plans. The scorecard results were published this past September. The top two plans with aggregated quality scores that ranked in the top 90s was Kaiser for both northern and southern California. The third ranked health plan was SFHP with an aggregated quality score of 88.

o Unfortunately, we didn’t receive the quality award at the last state’s medical director meeting. The award typically goes to the top three plans, however this year the state changed their scoring methodology. The reward was given

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using three tiers: high-enrollment, medium-enrollment, and low-enrollment. Kaiser San Diego received the low-enrollment award which we typically have received consecutively in past years. One might ask, “How can Kaiser win the low-enrollment award?” This is because Kaiser in this case is referring to their enrollment within San Diego County only.

o Cal Optima, Santa Clara Health Plan, and Kaiser San Diego were the winners respectively for high, medium, low-enrollment.

Consent Calendar

The consent calendar was reviewed and approved unanimously. • Review of Minutes – October 8, 2015 (p 3) • Health Services Update (p 16) • Member Report (p 20) • Members of Pharmacy & Therapeutics

Committee (p 25) & Minutes (p 26) • Policies & Procedures (p 39) • CLS-02 Use of Interpreters and Bilingual Staff • UM-10 Dental Anesthesia • UM Committee Minutes • October 2015 (p 40) • November 2015 (p 46) • Pain Management Evaluation Update (p 51) • Question from Irene Conway: “I have a

• Do the adult immunizations as a covered benefit apply to Health Workers?

Entire Consent Calendar approved Approved P&P’s: • CLS-02 Use of Interpreters

and Bilingual Staff • UM-10 Dental Anesthesia

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question on the Health Services update. It mentioned that adult immunizations (for example, flu, Pneumonia, Tdap, and Shingles) have become an added covered benefit since Oct. 1st – is this true?” Dr. Glauber says, “It has always been a covered benefit during doctor office visits but as a part of our access to care strategy, we are covering adult vaccines at pharmacies too. Pharmacists have immunization-prescribing authority.”

• Question: Does this cover Healthy Workers? In the past, Healthy Workers didn’t cover the vaccination for Shingles. Dr. Glauber replies that he can’t recall. Sari says she thinks it’s just Medi-Cal but we will verify.

Policies and Procedures

• Pharmacy-02 is our pharmacy authorization policy. Minor changes were made. The biggest change was made to turnaround (TA) times. We received guidelines from DHCS for the Medi-Cal line of business on what our TA times will have to be for pharmacy approvals, denials, or requests for additional information. Since Healthy Kids is not regulated by DHCS, there are different standards for TA times. For Medi-Cal, the policy changed from a 24-hour window to 30 days for pharmacy to issue a denial if sufficient clinical information had not been recieved. For Healthy Kids, DMHC standards states a 72-hour window. Desipite the 30-day increase seen in the Medi-Cal line of business, SFHP’s internal standard is to make a decision within 3 days. Additional language was added to Pharmacy-02 to make it more

• No follow up needed Approved: o QI-05 Timely Access

Standards o Pharm-14 Formulary

Exclusions, Limits & Quotas

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consistent with our other pharmacy policies like Pharmacy-07 that is related to our emergency medication supply. We will provide up to 5 days for emergency prescription. Some sections were deleted on Therapeutic Interchange, Step Therapy, and Non-Preferred Drug Authorization, and transferred to Pharm 14 - Formulary Exclusions, Limits, and Quotas – which was discussed at our last QIC meeting. Additionally, the sentence that states that we send approval notifications to members will be removed since we do not do this currently. When we go to NCQA for first survey, that is a requirement, so we will need to revisit this sometime in the future.

• Policy & Procedure QI-14 is related to SFHP’s internal Access to Care Committee. Essentially this is an outgrowth of both our DHCS CAP and SFHP’s strategic quality goal that Dr. Glauber mentioned regarding improving access to care. It’s a policy related to the workings of SFHP’s internal committee – how we monitor provider access standards, review the data to determine access, identify inefficiencies and corrective actions to correct those inefficiencies, identify interventions in improving member access, and assuring members and providers are receiving communication about our access to care standards. QIC will provide an oversight role by approving the Access to Care Committee meeting minutes in future QIC meetings.

• Question: Is this a new committee? Yes, this is

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a new committee and it is strictly internal, cross-functional and cross-departmental.

Motion to Approve. Approved. Quality Improvement

QI/UM Evaluation 2015 o QIC provides ongoing leadership for the QI

program, overseeing the annual work plan through quarterly monitoring that Anna provides. The committee’s role is to review and approve the QI evaluation and the subsequent year’s work plan.

o Before Sari started her presentation on the evaluation’s results, 2015 highlights, key influencers and improvement opportunities followed by the QI work plan, she acknowledged Anna Jaffe, Jessica Warren, and all contributing staff for the vast amount of work that went into preparing for this presentation and for the plan.

o In 2015, 59 measures were evaluated. Some were process measures and some were outcome measures. In 2016, SFHP will focus more on outcome measures like turnaround times, NCQA accreditation requirements, HEDIS requirements, and CAHPS. Overall the number of measures have decreased due this shift in priority for outcome-based measures. SFHP is committed to continuous improvement by increasing the rigor of all of these measures. The work plan and evaluation are aligned to meet our NCQA accreditation

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requirements. o The evaluation this year looked at the

efficacy of the 59 QI measures. The key results were summarized in a memo to Anna Jaffe, Jessica Warren, and Dr. Glauber. By looking at the QI program structure, leadership, and staffing resources, many improvements were identified for the 2015/2016 work plan.

o An addendum of the results will be brought to QIC in February.

o The overall rate is predicted to be 28 out of 59. QI measures are expected to meet the stated goals.

o There were two different measures that were discontinued mid-year due due to deprioritizing two different process measures. Again the focus is on outcome measures so that we can truly quantify and determine the outcome by the end of the year.

o A few highlights of 2015 include the implementation of a new Grievance Review and Oversight Committee that meets weekly, providing interdisciplinary review from different departments to ensure that all member aspects of the grievance are addressed. Additionally, the Practice Improvement Program (PIP) is now incentivizing both primary and specialty care. Specialty care is a very unique aspect of incentives in a pay for performance (P4P) program. SFHP has done tremendous

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work to make sure that the right people are in the room to make this incentive meaningful and make sure it translates into better patient care for members needing specialty. SFHP’s HEDIS scores are the third highest in the state and they are credited to the QIC board members for their commitment to the quality and level of care they bring to their practices and throughout the network.

o Access to Care in QI-14 established the Access to Care Committee to oversee network access monitoring. CAHPS is a continued improvement opportunity for SFHP and we’re committed to looking at our data. SFHP is starting an annual member satisfaction survey through CAHPS and we are continuously committed to improving our CAHPS scores as an organizational strategic goal for us this year, alongside access to care and NCQA accreditations.

o There were a number of key influencers that affected our daily operations and thus measures this year:

Medi-Cal Expansion with nearly a 60% membership increase.

SFHP’s Care Management Software System, Essette that was fully implemented in 2015.

NCQA interim accreditation

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requirements and program enhancements.

Beacon implementation and overcoming a seven month delay in implementation.

Continued focus on outcome measures. In the past we looked at our QI plan and we had many project and process measures that were easier to attain. But this year we are really looking at outcomes and ensuring that we are achieving the best patient care possible.

o Question from Edward: In regards to the Medi-Cal expansion, is there anything being done to consider the expansion of services to the medi-medi members? For example, San Mateo has a Medicare Managed Program included into their health plan. I think there is a great need for something like that here.

o Dr. Glauber states there are pilot programs including San Mateo County for an integrated medi-medi program. However, the state doesn’t have any plan to expand that to other counties until they do a fuller assessment. One of the challenges of those counties is that there is a very high-anticipated member opt-out rate. The short answer is, “No.”

o Despite all of these many influences and

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impacts to the health plan, we have determined that the overall staffing at SFHP really supported our QI program objectives through 2015.

o In terms of improvement opportunities, we have identified through this process that UM will start monitoring UM processes against defined metrics. NCQA has many defined metrics around under and overutilization and this is a process that we will start to implement next year. Additionally, delegation oversight through timely completion of audits coupled with providing technical assistance to providers to address the deficiencies found in the audit is a new improvement that will start next year.

o As we move toward NCQA accreditation, much work has been done in our Disease Management and Complex Medical Case Management programs. We seek to ensure that our providers know about these cohesive programs and have access to a seamless referral processes. We look toward the feedback we receive from our CAHPS survey to develop all the more interventions.

o As we move on to the QI Program description for next year, the QI Program infrastructure includes committee descriptions, staffing structure, and program overviews.

o Some enhancements include increased time

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in the QIC meetings, Grievance Oversight Committee, and Member Access to Care Committee. We also integrated additional patient safety measures such as flu vaccinations and medication therapy management.

o In the overall structure of the work plan, we focused on 29 outcome measures that are associated with 5 domains. We tried to evenly distribute the measures across all domains. QIC will receive quartetly updates on the performance of these measures.

o Question: Dr. Glauber asks, “Can you speak a little more about the percentage of the measures where we didn’t hit the target – whether or not there were barriers, etc.?” Sari says some measures had very high targets. Like for the HEDIS measures, even though we were performing in the 90th percentile, in some of the measures we were striving to hit even higher benchmarks than an already high target we were meeting. It appears that in some measures we set some unrealistic expectations, and we really are refining that process going forward on trying to find out what is a good threshold and what is a meaningful target. If we didn’t meet 100% of our target, we will provide an explanation of why we missed our target and what the barriers or challenges were going forward. In this way we can strategize on how to better address these measures in the following year’s work

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plan. o Jessica Warren says that for each measure

in the evaluation we write what our recommendations are for the upcoming year based on the obstacles and barriers we had faced. Our scores/percents for next year’s outcome measures that will be evaluated may be varied or stay the same, but this will indicate to us where we can continue to improve on how to meet and exceed each outcome measure in subsequent years.

o SFHP’s goal is the 90th percentile; however there is still a performance gap in the Medicaid and Commercial 90th percentile. In those cases where we are already at the 90th percentile, we will look at commercial plans as a comparison to perhaps set our target. Alternatively, we can look at the relative performance in our network and if some medical groups are reaching higher targets, we can have confidence that setting our target to a higher threshold will be reasonable.

o Question: I realize some metrics are dictated for SFHP to follow, but in terms of those that are not, what is the process of creating and choosing which outcomes become measures? And how does QIC participate in that?

o Sari mentions that each of the departments is charged with selecting their outcome measures, and they are aligned with DHCS

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requirements, NCQA requirements, and CAHPS. We also really look at our contract for our TA times and grievances, and that’s where the outcome piece is really dictated. We look towards those regulatory bodies for defining them.

o Dr. Glauber adds, “A part of it is the CAHPS, the DHCS CAHPS, in a particular area. They said we are not looking at over and under-utilization in a sufficiently rigorous way. Sari mentioned Beacon implementation for our new non-specialty mental health benefit was delayed due to DMHC approval. From the data Beacon has shared with us, we know that of all the Medi-Cal plans they are working with, we have the lowest penetration rate for that benefit. Penetration rate refers to the percent of our members that are utilizing the non-specialty mental health benefit. SFHP thinks there is an opportunity to improve the underutilization for this benefit, which is why you see that in our 2016 QI Work plan. We have set a pretty aggressive target to try to get up to 3%, recognizing that the top utilizing plan is 7%. It would be a 3-5 year goal to work towards that 7%. One of our strategies to eventually getting there is to offer a telemedicine benefit for behavioral health through a vendor that offers a range of services. The couple that SFHP is looking at offers video or telephonic mental health

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services. o The QIC role in helping define these

outcome measures will really be on a quarterly basis where we would like to hear provider input and feedback on why we select certain measures, how we can refine them for next year, and we’ll provide more information about the contract regulations as well. We really want to strive for alignment in our QI work plan and PIP program, and would like to receive clarity on our provider’s quality improvement strategies and efforts, so we can all be working towards similar goals and headed in the same direction.

o Question from Todd May: Quick question on over and underutilization since that is where managing the population is. You mentioned that NCQA had some metrics that we are aligning our to and I wanted to know more about those?

o Collin adds that NCQA actually does not have defined metrics. We are aligning more so with the DHCS contracts. The DHCS ‘generally’ states that you have to monitor over and underutilization of services. There is a large focus on inpatient management – the various levels of ED utilization, length of stay, etc. – the basic metrics. We looked at health plan data across the nation, local and down to the region level and we chose fairly aggressive targets. We have been performing at a pretty nominal level across

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the board for length of stays, denials, approvals and so forth. As a result, we chose a number of different measures that is California-specific and HEDIS-specific. There really is not a set standard on how this is captured in data so we had to do our best guess work.

o Dr. Glauber says that “a particular area we are focusing on as we work closely with SFHN in terms of over and underutilization is 30-day readmissions. That is why we really are focusing on discharge planning and follow-up after discharge.” Sari adds that this is a NCQA HEDIS measure.

Motion to Approve. Approved. Beacon Program Evaluation 2015 • Michelle Hernandez at the Beacon Service

Center in Cypress in Southern California presented the evaluation.

• The program evaluation is produced annually and reports are produced in Q1 of the following year for the year prior. For example, Q1 of 2016 for the year 2015. SFHP’s evaluation was atypically produced a little early, so the claim data covers up until November. The evaluation covers only the Medi-Cal line of business; no commercial. It does not include medical or pharmacy, but only behavioral health.

• The presentation covers the goals, interventions implemented in 2015, methodology, results, results analysis based on the findings, barrier

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analysis and next steps for 2016. • The areas that are covered in the program

evaluation include: o Clinical improvement activities such as

depression, alcohol and other drugs (AOD), and Attention Deficit Hyperactivity Disorder (ADHD).

o Monitoring of continuity and coordination of care

o Service improvement activities such as telephone access, appointment accessibility and availability, and the cultural and linguistic program.

o Patient Safety which covers timeliness of handling member complaints and adverse incident reporting.

o Geographic and Numeric Assessment Report.

• Items in blue will have slides in the presentation that is specific to that measure. Items in black are measured through chart review.

• There is one case for timeliness in handling member complaints, and none were found for adverse incident reporting.

• Dr. Glauber asks “What qualifies as adverse incident reporting?” Michelle replies that it calls for investigation when a member death is reported via natural cause or a member reports an incident related to a discrepancy in the quality of care or an experience with physical assault.

• Slide 5 reviews the metrics for depression.

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These metrics are plan-based. We have two measures that we are looking at: 1) Two or more visits within 12 weeks of initial diagnostic visit and 2) One or more medication visits within 12 weeks (84 days) of diagnosis.

• Both metrics had a target of 50% for 2015. A very small claims base of 41 members was used to score these metrics. SFHP scored 53.7% for the first metric and 0% for the second. The 0% could be a result of some providers not turning in claims data.

• Some barriers to accurately capturing these metrics for depression include: o A significant portion of members with a

depression diagnosis are likely receiving their prescriptions from a primary care provider. Beacon’s claims data does not capture this activity.

o Members may be resistant to treatment due to social stigma or cultural barriers.

o Members may stop service prematurely because they start feeling better

• Some of Beacon’s next steps are: o Collaborating with the health plan on

exchange of information and data. o Eliciting feedback from the Provider

Advisory Council (PAC) on how to improve the measures.

o Encouraging the utilization of the PCP toolkit.

o Working with the high volume providers to identify barriers in filing the claims accurately.

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o Providing education and support to providers via the Provider monthly newsletter, e-blasts, and on-going trainings.

• We also have a Quality Improvement activity that we have reconvened in that past month. It has centered on the measures for depression. We discussed what we can do across departments to improve these measures on how we can disseminate education to providers and members.

• Question by Todd May on the second measure on medication visits. Is there any way to capture PCP medication data? We would need to get that data from the SFHP. The next step for SFHP is to continue to develop a process with Beacon to retrieve and capture this data.

• Alcohol and Drug (AOD) contains two measures. o Is there documentation that the member

was screened for alcohol or other substance abuse or dependence? (13 yo+)

o If the member screened + for abuse/dependence, was this included in the diagnosis and/or treatment plan OR is being addressed on an on-going basis as part of treatment?

• We just requested charts and received 4 of 20 back. Of those 4, they did screen for on-call so we were 100% on that measure. Of the four charts screened, they did not show evidence of alcohol or other drug use. This could be due to members not reporting substance use. Perhaps providers are screening and not documenting.

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We will continue to do more chart audits. Ten charts have been turned in and will be added to this data for our update in Q1.

• Question: I see that there were low numbers for those who screened positive. For those who do screen positive, perhaps they decided to not receive therapy. I just want to make sure that upon diagnoses, that there is proper documentation and action taken, especially if a person screens positive. Michelle answered, “Yes. However, from the 4 cases submitted this time around, the diagnoses were negative and were properly documented.”

• Question: What is the expectation for how many charts need to be screened to have validity in assessing these measures?

• We try to review the top 10% of high-volume providers. Given the short time frame that we have been live with the plan, we have found high-providers sending us less right now since there aren’t enough claims in the system. But typically, this is the protocol we follow and from those patient records we focus on members that have been at least seen three times. Ultimately, our goal is 4-6 charts per provider for a total of at least 30 charts.

• Dr. Glauber asks that given the limit in time to discuss, “Michelle, could you focus more on the service improvement activities?” One of the issues in members utilizing the benefit is that members need to be triaged when they self-identify having a need and determine if they fit in the Beacon scope of services or specialty

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mental health. Members have to go through a screening process with Beacon so telephone access, timeliness, and the customer service experience with Beacon are crucial in receiving access. Beacon has had some challenges there so it would be good to hear about those.

• Under telephone access there are 4 measures: o Call Abandonment – The target was less

than or equal to 3%. SFHP scored 6.35%. o % answered Within 30 seconds – The target

was greater than or equal to 90%. SFHP scored 57%.

o Average Seconds to Answer – The target was less than or equal to 30 seconds. SFHP scored 83.20

o Call Volume – There is no target, but SFHP had a volume of 834.

• One thing Beacon is doing to meet call time targets is to hire more call representatives hopefully with previous customer service experience to ensure high quality of service to members.

• Additionally, there has been more focus on staff productivity to ensure accurate information is being given. There has been a revamp of the customer service team, adding team leads and training smaller groups of people to focus or specialize in different health plans. We hope that this realignment of our resources will hopefully improve all the metrics. It is currently being built, and we think this will improve all metrics and the customer service delivered at the front line.

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• Laura adds, “We have spent a lot of time looking over these numbers and we want to be meeting our service agreement but most importantly meeting member satisfaction and directing them to care and the correct resources. We have had cross-department meetings and discussed these improvements. We believe staffing will be a key piece. We already brought on a number of new service members that we are now training. We are building team leads for oversight and the assistance of training new staff. A key change we are making in the new year is developing a number of service staff that is focused on a region and have plan specific knowledge. This will increase both the basic measures we are looking at here and also member satisfaction. Members will be connected to what they really need through local team knowledge. We are changing our structure to make sure that we are meeting these measures and serving members.

• Dr. Glauber says, “It is a process of the member calling Beacon, Beacon answering the phone and determining if the member is SFHP-eligible. From there, the Beacon representative needs to connect the member to a clinician for a screening to determine if they are specialty health and non-specialty mental health.

• A warm-hand off from Beacon customer service to a clinician is done to ensure that a member is screened to determine if the member’s condition is low to moderate or moderate to severe and thus directed to Beacon

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or to the country for those respective diagnosis. • The service representative can also refer a

member to a provider if they are within our network. A member can be directed to management if they need more assistance. A service representative can further assist a member in making an additional appointment if help is needed with that or be referred to the county.

• Previously, sometimes it would require a call-back and take several days for a clinician to get back to a member. Beacon does facilitate following-up with members if needed to decrease and member dropping off from the radar.

• Question: Is the customer service available in different languages?

• We have staff with a language capacity and a language line. Members are always able to access that language line if needed. Slide 11 shows all our information about Culture and Linguistics. The number and percent of callers (SFHP) who called Beacon and used one or more language interpreter services was 10.7%. The percent of plan members who requested translation services was zero. We do maintain a bilingual line of 18.9%.

Motion to Approve. Approved.

Delegated Medical Groups QI

• The audit process is managed by O. Bigler and the audit evaluation is completed by experts in this area. Jess Strange reviewed medical groups

• Odalis to revise IHA and IHEBA summary of results.

n/a

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and HECLS Audit Results

QI program and Cassie Caravello reviewed the HECLS requirements.

• This is the first year we audit the QI programs for Hill, Brown & Toland, CCHCA, and NEMS. Kaiser results are pending.

• The QI audit methodology included a review of the QI Program, policies a and procedures, and Medical Record Reports (MRR) reports. The QI includes a review of PCP’s completion of Initial Health Assessments (IHA), Initial Health Education Behavioral Health Assessments (IHEBA), wait time in the providers’ office, and follow up on missed appointments.

• The overall QI audit score for each of the medical groups are: o Brown & Toland – 69% o CCHCA – 88% o Hill Physicians – 57% o NEMS – 76%

• SFHP requested a CAP for all the groups that scored less than 95% audit score.

• Follow up on CAPs will begin as soon as January 2016.

• There is an error in the summary report for NEMS’s scores.

• The HECLS audit methodology included a review of policies a and procedures, cultural sensitivity training materials, and evidence of completion.

• The overall HECLS audit score for each of the medical groups are: o Brown & Toland – HE 88% / CLS 72% o CCHCA – HE 100% / CLS 80%

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24 | P a g e

o Hill Physicians – HE pending / CLS 70% o NEMS – HE 75% / CLS 100%

• The results from the Kaiser, UCSF, and SFHN audits are pending.

• SFHP requested a CAP for all the groups that scored less than 95% audit score.

• Follow up on CAPs will begin as soon as January 2016.

• Dr. Glauber asks if the internal SFHP committee structure that is providing more on-going oversight can be described? Odalis mentions that last year the Delegated Network Oversight Committee (DNOC) had been created. This committee is chaired by the Director of Provider Network, and voting members are the Directors of Health Improvement, Clinical Ops, Finance, Operations, Pharmacy, and Compliance Officer. The reason why we chose this membership it is because oversight of a medical group includes QI, UM, Provider Credentialing, Claims, Network Management, Pharmacy, and Compliance. The committee reviews how we do audits and implement monitoring activities. Audits are done once per year and monitoring activities can be done at multiple times throughout the year. Ultimately, this committee will determine what to do next if we find that a medical group as a whole has a problem. QIC is different in that we present the QI audit results and ask for any feedback and expertise in certain areas. Each of our committees – QIC, UM, PAC and Grievance

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25 | P a g e

focuse and use the expertise of internal and external leadership to come together and collaborate to find solutions and recommendations that best inform our providers.

• Question: What about translation services for non-medical providers? For example wheelchairs, physical therapy, and resources like that. Response: All of our providers are required to offer a interpreting services, and if the there is no one in the office that can speak the language of preference, the provider should be able to call the language line and find that interpreter over the phone.

• Question about the statistics of the CAPS: Dr. Chan wanted to clarify that for the QI Audit, all medical groups need improvement in their QI activities and cultural and linguistic services. Odalis assures that SFHP will work collaboratively with each medical group to improve these areas. In addition to QI and cultural and linguistics, improvement across medical groups is needed in health education and case management and coordination.

• Dr. Critchfield asked how can we help you? Providers on the panel of QIC are knowledgeable of the QI areas that may need improvement in their respective medical group, and Odalis just asked members to bring these issues of concern or expertise to QIC. QIC members know what is happening for SFHP QI and all these activities. If there are any suggestions you have or any feedback, SFHP

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26 | P a g e

would like to hear.

QI Committee Chair's Signature & Date: 12/18/15 Minutes are considered final only with approval by the QIC at its next meeting.

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HEALTH SERVICES UPDATE Pharmacy Pharmacy Benefit Management Update Excelsior Solutions, our pharmacy consultant, is leading a Specialty Pharmacy request for proposals (RFP) effort to ensure we are providing the best services available for our members on specific medications that require extra support for handling, storage, side-effect management, compliance management and avoidance of wasted medication. The RFP was issued on December 4, 2015. Proposals will be due in January, with the final selection of a vendor expected by March 1, 2016. The target date for implementation is July 2016. SFHP’s PBM, PerformRx, has committed to a detailed Corrective Action Plan (CAP) aimed at quickly fixing deficiencies in operational accuracy, customer service standards, and account management. We are seeing improvements and will be monitoring Perform Rx closely (with the assistance of Excelsior Solutions) to ensure this focus is maintained until all deficiencies are addressed. We expect this to take no longer than three months. PerformRx is extending the hours of operation for their prior authorization team to ensure SFHP will meet all regulatory turn-around times during long weekend holidays. This was in place for the Thanksgiving four-day holiday. Home Blood Pressure (BP) Cuffs Update In August 2015, SFHP pharmacy services began covering home blood pressure (BP) cuffs (up to $50 cost) for our members available through their local pharmacy. Members can obtain one BP cuff every five years. To date, we are pleased to see that home BP cuffs have been dispensed to 915 members (65% from NEMS pharmacies, 27% from Walgreens, 8% from other pharmacies.) Hepatitis C Treatment Update The SFHP Pharmacy staff is profiling all of our members on Hepatitis C medications to monitor our treatment completion rates and to follow-up on members where treatment has been interrupted. To date (from December 2013 to November 2015), 222 SFHP members received Hepatitis C medications, of which 104 (47%) have completed treatment. Forty members (18%) are being assessed for interrupted treatment and possible non-compliance. SFHP has over 3,000 active members with a Hepatitis C diagnosis code recorded in their claim history. For Q3 2015, Hepatitis C medications accounted for 31% of total

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pharmacy spend (68% of the specialty pharmacy costs managed by our specialty pharmacy vendor). Practice Improvement Program (PIP) SFHP has completed both the 2016 PIP Primary Care and PIP Specialty measure sets (Please see Attachment 2 for 2016 PIP measures). Notable changes in the 2016 measure set include: 1) increased focus on patient access (including CAHPS performance and expansion of patient care service in the primary care setting); 2) incorporating incentives for sustaining improvements from 2015; and 3) adding measures that address improving specialty access for the delegated medical groups. Improving data quality has been an area of focus for SFHP. Last year, we piloted a PIP measure that incentivized improved data accuracy between the medical chart and the encounter data sent to SFHP. This year, we expanded the measure, incorporating a self-audit opportunity so participants can better identify the source of data quality issues. DHCS Health Homes for Patient with Complex Needs (HHP) Concept Paper Update Section 2703 of the ACA authorizes states to establish the Medicaid Health Home State Plan Option, which would provide Medicaid members with chronic conditions a full range of team based, physical and behavioral health services, and community based long term services and supports. The goal is to meet the Triple Aim: better care, better health outcomes and lower cost. Section 2703 provides a 90% federal match for eight quarters to states implementing this state option. Additionally, legislation signed by Governor Brown in 2013 authorizes the California Endowment to match the remaining 10% of the cost, up to $25 million annually, subject to an evaluation after two years and a finding of state General Fund neutrality. Funding beyond the eight quarters would be a 50:50 state/federal match and require cost avoidance to ensure overall budge neutrality for state general funds. Version 3.0 of the HHP concept paper was released on December 14th and includes key updates from the prior version 2.0, including more detail about population eligibility, HHP MCP responsibilities, payment methodologies, reporting requirements, inclusion of lists of counties proposed for phases 1 and 2, and an updated timeline. As stated from the outset, the HHP will be operated through Medi-Cal managed care plans (MCPs), which will establish networks of community based providers (CB-CMEs) and/or use current managed care support outreach teams as CB-CMEs to offer HHP services outlined in the concept paper. These include such as comprehensive care management, care coordination and health promotion, transitional care, individual and family support services, and referral to community and social supports. Each of these services is outlined in detail in Version 3.0.

KEY HHP UPDATES

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I. Eligibility criteria: The state will provide MCPs with targeted engagement lists based on chronic conditions (both medical and mental health) and risk scores OR inpatient/ED used in the prior year. The proposed eligible population will include no more than 5% of total membership. While not stated in the concept paper, we understand that DHCS may choose to release two separate program cycles with a subset of the total eligible population. The first would focus on individuals with severe mental illness (SMI) and the second would begin six months later and include all other eligible individuals based on the above criteria. The eight quarters of funding would start separately for each of the two cycles. II. HHP MCP responsibilities and network structure Version 3.0 includes more detail regarding MCP responsibilities as a part of HHP and outlines expectations for both our Care Coordination and Clinical Operations departments. We anticipate that Care Coordination staff would serve as a Community Based-Care Management Entity (CB-CME) and meet the requirements of training, supporting and qualifying community CB-CMEs. Additionally, our Clinical Operations departments would be asked to assist the community CB-CMEs with information on admissions and discharges. The DHCS must certify readiness by the Medi-Cal managed care plan prior to implementation and MCPs will be required, 6-9 months before HHP implementation, to submit a detailed proposal to DHCS regarding how the HHP will be implemented and outlining the proposed network structure. III. Payment Methodologies All payments will flow from DHCS to MCPs, who can contract with community CB-CMEs for reimbursement of HHP services. DHCS will pay different rates for 1) the engagement period and 2) the ongoing service delivery period. The engagement period can last up to three months. This rate will be “based on percentage of the monthly ongoing service delivery period rate.” Once a member consents, the rate will switch to the ongoing service delivery rate. Rates will be developed with the help of actuaries that will be based on the member’s acuity and intensity of service needs. MCPs will receive HHP payments through capitation rates that will include a monthly add-on risk based PMPM payment. IV. Reporting Version 3.0 provides more detail about MCP reporting requirements. MCPS will be expected to report how many of their members meet and are accessing HHP services by category of aid (COA) on a member month basis. MCPs will also provide cost and utilization reporting related to HHP member services including the number and associated cost of service, also at the COA level. V. Timeline

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San Francisco was chosen as a Phase 1 county with an implementation date of January 1, 2017 for members with Serious Mental Illness. There will be an RFP released in January 2016 for additional counties that will also be implemented January 1, 2017.

Clinical Operations Clinical Operations continues to implement several process enhancements to improve member outcomes and the provider experience. On December 1, 2015, the concurrent review team implemented a Discharge Planning program (DCP) that initially will be focused on the California Pacific Medical Center (CPMC) facilities and connecting Community Health Network (CHN) members with primary care physicians (PCP) or specialists post discharge. The concurrent review nurses will reach out to members and case managers during the admission and will verify the members’ PCP and determine if any follow up is required. If required, the nurses will then contact the utilization management department at San Francisco General Hospital and will schedule a visit. The appointment information will be sent to the member. Also determined during the discharge process will be barriers to discharge, identification of multiple admissions or emergency department usage, and medication concerns. Once a smooth process is established, this process will be expanded to all facilities and will include a referral process to internal and external coordination of care resources and follow-up phone calls to the members. Implementation of the action items from the Corrective Action Plan for the 2015 DHCS audit is still continuing. A joint initiative between Compliance and Clinical Operations to review random utilization management files for contractual and regulatory compliance was executed this quarter. This audit will focus on turnaround times for UM decision making, Notice of Action appropriateness and timeliness, and clinical appropriateness. This review will be performed at least semi-annually and results will be reported to the UM Committee. The fourth quarter marked the end of the delegation oversight audit season with the joint efforts of Clinical Operations and the Provider Network Operations (PNO) department. The final results were reported to the UM Committee on December 15, 2015 and will be included in the Quality Improvement Committee (QIC) meeting materials. Calendar year 2016 will be focused on ensuring that the data and process improvements implemented in 2015 are readily available and remain in place for the 2016 DHCS Audit. Clinical Operations will continue to collaborate with SFHN, SFGH, and the other external customers to ensure we have an effective and efficient process. The expansion of discharge planning, potential revisiting of inpatient-to-inpatient repatriations, clinical quality ramp up, and Prior Auth policies will serve as the primary initiatives for the upcoming year.

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California HealthCare Foundation’s (CHCF) initiative, Care Integration for Opioid-Dependent High Utilizers (Planning Grants) We are pleased to share that SFHP’s and BAART’s application to the California HealthCare Foundation’s (CHCF) initiative, Care Integration for Opioid-Dependent High Utilizers (Planning Grants) was awarded the planning grant. The grant is a six-month planning grant to develop a system of care and a payment model to address the needs of SFHP members who are dependent on opiates and are also high utilizers of ED and other services. BAART has implemented a “Hub and Spoke” model successfully in Vermont, that has lowered costs and led to increase in access for substance abuse treatment services. We will work with BAART and SFHP network partners to look at ways a similar model could be implemented in our network. The San Francisco Safety Net Pain Management workgroup will be involved in the planning process.

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2/8/2016 1

Participant Report - February 2016Department: Marketing & Communications

Healthy San Francisco (HSF) ParticipantsFeb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-1616,334 16,192 15,992 15,540 15,380 15,202 15,235 15,135 14,742 14,638 14,632 14,382

Net New -1,814 -142 -200 -452 -160 -178 33 -100 -393 -104 -6 -250% New -6.94% -0.87% -1.24% -2.83% -1.03% -1.16% 0.22% -0.66% -2.60% -0.71% -0.04% -1.71%

Annual GrowthJan-16 14,382Jan-15 17,942

Change -3,560 -19.8%

Med Home Type # %SFCCC 5,026 34.95%SFDPH 8,383 58.29%Kaiser 680 4.73%

BTP 0 0.00%CHW 274 1.91%

CCHCA 0 0.00%BAART 19 0.13%

Total 14,382 100.0%

FPL # %0-100 8,806 59.97%

100.01-138 1,637 11.15%138.01-200 2,417 16.46%200.01-300 1,382 9.41%300.01-400 412 2.81%400.01-500 23 0.16%

501+ 6 0.04%Total 14,683 100.0%

Global membership decreased by 1.71% (250 members) from January 2016 to February 2016; and decreased by 19.8% (3,560 members) since January 2015.

*These numbers reflect data as of 1/31/2016**There was 1 participant who was unassigned under SFDPH. That particpant was not added to the Medical Home counts.

16,334 16,192 15,992 15,540

15,380

15,202

15,235 15,135 14,742

14,638

14,632

14,382

10,000

11,000

12,000

13,000

14,000

15,000

16,000

17,000

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2/8/2016 2

Healthy San Francisco Participants by Medical Home (Overview)Med Home Type # %

SFCCC 5,026 34.9%SFDPH 8,383 58.3%Kaiser 680 4.7%

BTP 0 0.0%CHW 274 1.9%

CCHCA 0 0.0%BAART 19 0.1%

Total 14,382 100.0%

Healthy San Francisco Participants by Medical Home (Detail)

SFDPH # % DPH % TOTAL SFCCC # % SFCCC % TOTALFamily Health Center 2,763 33.0% 19.2% NEMS - Portola 118 2.3% 0.8%

Castro Mission Health Center 1,205 14.4% 8.4% NEMS - Sunset (Taraval) 17 0.3% 0.1%General Medicine Clinic 1,389 16.6% 9.7% NEMS - Richmond (Clement) 56 1.1% 0.4%

Silver Avenue Family Health 1,140 13.6% 7.9% NEMS - Sunset (Noriega) 145 2.9% 1.0%Ocean Park Health Center 126 1.5% 0.9% NEMS - Chinatown North Beach 209 4.2% 1.5%

Chinatown Public Health Center 134 1.6% 0.9% Mission Neighborhood 1,542 30.7% 10.7%Potrero Hill Health Center 315 3.8% 2.2% Sourth of Market Senior Center 4 0.1% 0.0%Maxine Hall Health Center 379 4.5% 2.6% St. Anthony Medical Clinic 1,006 20.0% 7.0%

Southeast Health Center 366 4.4% 2.5% Tenderloin Health Services 418 8.3% 2.9%Positive Health 150 1.8% 1.0% Haight Ashbury Free Medical Clinic 180 3.6% 1.3%

Housing and Urban Health Clinic - 0.0% 0.0% Haight Ashbury Integrated Care Center 226 4.5% 1.6%Tom Waddell Health Center 294 3.5% 2.0% Lyon-Martin 42 0.8% 0.3%

Young Adult / Teen Health Center 87 1.0% 0.6% Mission Neighborhood Resource Ctr 202 4.0% 1.4%Curry Senior Center 27 0.3% 0.2% Native American Health Center 84 1.7% 0.6%Larkin Street Clinic 8 0.1% 0.1% Mission Neighborhood-Excelsior 399 7.9% 2.8%

Cole Street Clinic - 0.0% 0.0% NEMS - Visitation 20 0.4% 0.1%Not Provided - 0.0% 0.0% South of Market Health Center 358 7.1% 2.5%

TOTAL SFDPH 8,383 100.0% 58.3% TOTAL SFCCC 5,026 100.0% 34.9%

CCHCA # % CCHCA % TOTALCCHCA/Chinese Hosp 0 0% 0.0%

Kaiser # % KP % TOTAL TOTAL CCHCA 0 0.0% 0.0%Kaiser 680 100.0% 4.7%

TOTAL KP 680 100.0% 4.7% BAART # % CHW % TOTALBAART Comm Hlth Ctr 19 100.0% 0.1%

CHW # % CHW % TOTAL TOTAL BAART 19 100.0% 0.1%Sr Mary Philippa Hlth Cntr 274 100.0% 1.9%

TOTAL CHW 274 100.0% 1.9% BTP # % CHW % TOTALBrown & Toland Physicians 0 0% 0.0%

TOTAL BTP 0 0.0% 0.0%

5,026

8,383

680 0 274 0 19

0

2,000

4,000

6,000

8,000

10,000

SFCCC SFDPH Kaiser BTP CHW CCHCA BAART

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2/8/2016 3

37

2/8/2016 438

0.05 Q3-15_Final_AppealsRpt_QIC_v12 02 15.docx

Prepared by: K. M. McDonald (11.24.15) Page 1 of 7

Q3-2015 UM Medical and Pharmacy Appeals Activity UM Medical and Pharmacy Appeals Activity – Overview

There were a total of 43 medical and pharmacy appeals1 filed during Q3-15 out of a quarterly total of 7,623 medical and pharmacy authorizations2. On a per 1,000 authorizations basis, 5.64 appeals per 1,000 authorizations3. Q3-15 compared to Q2-15:

• 31% decrease in the number of appeals4 • 32% decrease in the appeals per 1,0005

Of the 43 appeals, 26 appeals resulted in denials overturned, a 4% decrease over Q2-15 (27 appeals overturned). A summary of the types of Q3-15 services appeals is proved in a later section, Types of Services Handled in UM Medical and Pharmacy Appeals.

1 Source: 0944ES A&G UM APPEALS REPORT: AUTH RECEIPT DATE: AUTH RECEIPT DATE: 7/1/2015 - 9/30/2015 as of 11/6/2015 2:49:18 PM. This is an aggregate number of medical and pharmacy appeals; all members (43) appealing were Medi-Cal members. 2 Source: Pharm_2015-10 Prior Authorization Summaries-Statistics (3,235 authorizations) and Medical_Auths Approved and Denied by Requested Month_9 8 15 (4,388 authorizations). 3 7,623 authorizations / 1,000 > 43 appeals / 7.62 authorizations = the quotient 5.64 appeals per 1,000. 4 Q2-15 = 63 medical and pharmacy appeals. 5 Q2-15 = 8.32 appeals/1,000 medical and pharmacy authorizations

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UM Medical and Pharmacy Out-of-Medical Group / Out of-Network Appeals Activity There were a total of 3 medical appeals: 2 for out-of-medical group and 1 out-of-network. The adjudication of the appeals resulted in 2 appealed denials were overturned and 1 appealed denial was upheld. Q3-15 compared to Q2-15:

• 40% decrease in the number of medical Out-of-Medical Group / Out-of-Network Appeals.6

• 66% decrease in the number of appealed denials upheld7

6 Q2-15 = 5 Out-of-Medical Group / Out of-Network appeals. 7 Q2-15 = 2 appeals were overturned (no change from Q3-15) and 3 appeals were upheld.

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UM Medical and Pharmacy Appeals Activity per 1000 Authorizations The impact of appeals activity on authorization reviews in Q3-15, per 1,000 authorizations, is 5.64 appeals per 1,000 authorizations8, as compared to, 8.32 appeals per 1,000 authorizations in Q2-15.

8 7,623 authorizations / 1,000 > 43 appeals / 7.62 authorizations = the quotient 5.64 appeals per 1,000.

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UM Medical and Pharmacy Appeals Activity by Department

During Q3-15, of the 43 total appeals, 30 (70%) involved pharmacy and 13 (30%) involved medical management. Quarterly totals to date, out of a total of 175 appeals, 69% involved pharmacy (121 appeals) and 31% involved medical management (54 appeals).

Appeal Activity Q1-15 Appeal Activity Q2-15 Appeal Activity Q3-15 2015 Quarters to DateRx Appeals Upheld 33 27 11 71

Rx Appeals Overturned 10 21 19 50Total Rx Appeals 43 48 30 121

UM Appeals Upheld 12 7 5 24UM OON Appeals Upheld 1 3 1 5UM Appeals Overturned 11 5 5 21

UM OON Appeals Overturned 0 2 2 4Total UM Appeals 24 17 13 54

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UM Medical and Pharmacy Appeals Activity by Medical Groups

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Types of Services Handled in 3Q-15 UM Medical and Pharmacy Appeals

Type of Services Medical Appeals Upheld Frequency Pharmacy Appeals Upheld Frequency

Q3-15 Uphold the original denial to deny the consult for a vaginoplasty

Uphold the decision to deny your request for HARVONI 5

Uphold the original denial; Brown and Toland Physicians has these physical therapy services with its network; specific methods of physical therapy such as Feldenkries or Pilates are not a

Uphold the decision to deny your request for MEKINIST

Uphold the original denial decision for additional skilled nursing home health visits

Uphold the decision to deny your request for Oxycontin 10mg tablet #90 per 30 days as the total prescribed dose of 30 mg is achieved through #60 per 30 days of 15 mg tablets

Uphold the original denial; Hepatitis C medications

Uphold the decision to deny your request for Viekira Pak

Uphold CCHCA’s original decision; a MRI doesn’t meet medical necessity as there is no evidence of persistent symptoms after physical

Uphold the original denial decision for medication, but the type of medication was not specified

Uphold the decision to deny your request for BRCA testing

Q3-15 Medical Appeals Overturned Frequency Pharmacy Appeals Overturned Frequency MRIoA and IPA Appeals Decisions Frequency

Approve the genetic testing for HHT Overturn the decision to deny your request for HARVONI and approve this medication 12 Medical Review Institute of America (MRIoA)

determined Harvoni and Ribavirin were not

Approve the powered wheelchairOverturn the decision to deny DRONABINOL 5 MG CAPSULE and approve this service as requested for continuation of care

Independent medical providers found Harvoni to be medically necessary.

Approved the office visits at Boston Medical Center and Dana Farber Cancer Institute; a rare blood disease

Overturn the decision to deny your request for Dronabinol and approve this service as requested

Approve the facial electrolysis Overturn the decision to deny your request for Dronabinol because of your anorexia

Approve the photodynamic therapyOverturn the decision to deny FLUOCINOLONE ACETONID BODY OIL and approve this service

Overturn the decision to deny Moxifloxacin and approve this service as requested

Overturn the decision to deny for Wheelchair Repairs to a Secondary Ultra-lightweight Wheelchair and approve the service as requested

Overturn the decision to deny OPSUMIT and approve this service as requested

Overturn the decision to deny Varicose Vein treatment at St. Mary’s Hospital and approve this service as requested

Overturn the decision to deny TAZORAC 0.05% cream and approve this service as requested

Approve Lidocaine 5% PatchApprove the OxyContin 10mg tablet

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Analysis The average quarterly membership between Q2-15 and Q3-15 increased by 3% (136,591 > 140,184) with a 31% decrease in appeals. Medical Appeals Analysis UM appeals decreased from Q2 to Q3 2015 as new criteria for wheelchairs and transgender services is implemented. The facial electrolysis appeal and wheelchair appeal both benefitted from the revised criteria. The other overturned appeals were reviewed in UM Committee and all of them were related to the introduction of additional information not available at the time of initial request. Actions

• Continue to review UM overturned appeals in UM Committee and when applicable, recommend and implement process enhancements.

• The Utilization Management Committee (UMC) has standing agenda items to (1) review, (2) discuss the medical management and pharmacy appeals. These topics were discussed during the UMC’s Q3-2015 meetings.

Pharmacy Appeals Analysis The total number of Rx appeals from Q2 to Q3 decreased from 48 to 30 likely due to the change in the DHCS treatment criteria for Hepatitis C (released in July 2015) which now allow treatment of F2 and higher instead of F3 and higher. Other treatment requirements such as urine toxicology screen, documentation of Hepatitis A and B vaccination or screening, and HIV screen were also removed from the new criteria allowing more HCV requests to be approved during the initial review.

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San Francisco Health Plan Pharmacy & Therapeutics Committee Wednesday January 27, 2016 7:30AM - 9:30AM 50 Beale St., 12th Floor, San Francisco, CA 94119 Voting Members present:

James Glauber, MD (SFHP Chief Medical Officer) Lisa Ghotbi, Pharm.D. (SFHP Director of Pharmacy) Ron Ruggiero, Pharm.D., OB-Gyn Roger Tiao, Pharm.D. Linda Truong, Pharm.D. Brad Williams , MD Jaimer Ruiz, MD (e-vote 01/28/16)

Members Absent

Jamie Ruiz, MD Kathleen Liu, Pharm. D. Ted Li, MD Shawn Houghtaling, Pharm.D. Joseph Pace, MD Lauren Goldman, MD

Others Present:

Olga Mostovetsky, Pharm. D (SFHP Clinical Pharmacist) Dai Tan, Pharm.D (SFHP Pharmacy Resident) Kenneth Garcia, CPhT (SFHP Analyst, Pharmacy Services) Alicia Wong (UCSF Student) Andrew Costiniano, CPhT (SFHP Pharmacy Coordinator) Jenna Heath, Pharm.D. (PerformRx Clinical Pharmacist) William Lam, Pharm.D. (PerformRx Clinical Account Executive) Alan Kaska (Abbott) Jennifer Denning (Bristol Myers Squibb)

TOPICS and DISCUSSIONS OUTCOME/ ACTION

I. Call to Order & Introductions

A) Agenda overview and other topics - (James Glauber) – 2 minutes

B) Informational Updates –(James Glauber, Kenneth Garcia) -non-voting item -5 minutes

• Introduction of new Director of Pharmacy, Lisa Ghotbi

• Acute Pain Management online training by Healthcare Concepts (go-live Feb 2016)

• Implementation of 90 days supply policy for maintenance brand medications effective 11/1/15

• Auvi-Q and Ventolin recalls • Blood Pressure Utilization

James Glauber, MD called the meeting to order at 7:32am, introduced Lisa Ghotbi as the new Director of Pharmacy and provided a brief overview of the upcoming on-line acute pain management CME training. James Glauber, MD reviewed the implementation of an online training by Healthcare Concepts for Acute Pain Management. Further details regarding this will be emailed to the committee members. Kenneth Garcia, CPhT discussed:

• Implementation of the 90 day supply policy for brand medications for select chronic conditions which was implemented to increase access and provider and patient satisfaction.

• Auvi-Q nationwide recall: PerformRx has identified 6 SFHP members who have filled Auvi-Q. Aside from PerformRx’ network pharmacy faxblast, SFHP also mailed out recall notifications to the 6 impacted members.

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C) Review and approval of October 21, 2015 P&T minutes – (James Glauber) – 2 minutes – vote

D) Adjourn to Closed Session – 60 minutes • Discussion and Recommendations for changes to

SFHP Formulary and Prior Authorization Criteria for select drug classes - 40 minutes -vote o Urinary Antispasmodics o Inhaled Corticosteroids o Acne medications

• Additional Proposed Changes to SFHP Formulary –

5 minutes – vote • Closed Session pursuant to Welfare and Institutions

Code Section 14087.36 (w) Olga Mostovetsky, PharmD, Clinical Pharmacist, San Francisco Health Plan

E) Reconvene in Open Session F) Summary of Closed Session – (James Glauber MD, CMO)-2

minutes –non voting G) Annual SFHP Prior Authorization Criteria Review –(Olga

Mostovetsky and Dai Tan)- 40 minutes –vote H) Review and approval of Interim Formulary Changes and

Formulary Placement for New Drugs to Market –(Olga Mostovetsky and Jenna Marks)-15 minutes-vote

I) Follow up discussion from July2015 P&T Committee Meeting –(Olga Mostovetsky and Kenneth Garcia) – 5 minutes- non-voting

J) Informational Update on New Developments in the Pharmacy Market –(Jenna Marks) -5 minutes- non-voting item

K) Adjournment • Next P&T Committee meeting – 2 minutes

o Wednesday, April 20, 2016 • P&T Committee Member Forms

• Ventolin HFA lot level recall: based on FDA website, affected lot #s were only distributed to Mississippi and Vermont. Since this is a lot# recall, it is unlikely that SFHP members are affected, so no further action has been taken.

• Blood Pressure Utilization: covered as pharmacy benefit effective 8/1/15 as discussed in October P&T Meeting. Since implementation through 12/31/2015, there have been 1574 claims for 1574 unique member IDs for BP monitors.

Dr. Glauber noted that the utilization for Blood Pressure monitors has been robust.

II. Review and approval of October 21, 2015 P&T minutes P&T Meeting Minutes

(James Glauber, MD, CMO) – 2 minutes- vote

The committee approved 10/21/2015 P&T minutes. Motion: Brad Williams, MD Second:

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2015_10_21_PT_Minutes_signed

Votes: 7 Approved,0 Denied,0 abstained Notes: Alan Kaska and Jennifer Denning left the room at 7:39am due to closed session.

****Adjourn to Closed Session**** Closed Session pursuant to Welfare and Institutions Code Section 14087.36 (w)

III. Discussion and Recommendations for Changes to SFHP Formulary and Prior Authorization Criteria for Select Drug Classes (Jenna Marks, PharmD, Regional Clinical Pharmacist, PerformRx and Dai Tan, PharmD, Resident) – 40 minutes – vote

A)

1. Urinary Antispasmodics • Proposed Formulary Changes • PA Criteria

Current_Criteria_Urinary_Antispasmodics

3.1.02_Proposed Formulary_Changes_

The P&T Committee reviewed and voted on the following items: III.A.1 Urinary Antispasmodics Votes: 7 approved, 0 denied, 0 abstained 1st Motion: Ron Ruggiero, Pharm.D. 2nd Second: Roger Tiao, Pharm.D. Notes: Jenna Heath, PharmD, presented on the antispasmodic agents for urinary incontinence. Topics covered included their place in current clinical guidelines, pharmacology, formulary status, current PA criteria, cost, utilization, PA history, proposed formulary status changes and proposed PA criteria. Clarification was made that the standard step therapy look back period is 180 days. Ron Ruggiero, PharmD stated that he is surprised that Mybetriq is not requested more given the advertisements on TV. Per Jenna Heath, PharmD, this may be due national guidelines not recommending Mybetriq over the older agents. Toviaz was originally proposed to have Step Therapy but due to recent pricing changes, recommendation was made to keep Toviaz non-formulary. Approved changes can be found at the following locations:

Formulary changes: under “Materials” section at http://www.sfhp.org/providers/formulary/pharmacy-therapeutics-committee/

PA criteria: http://www.sfhp.org/files/providers/formulary/Prior_Auth_Criteria.pdf

2. Inhaled Corticosteroids • Proposed Formulary Changes

III.A.2 Inhaled Corticosteroids

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http://www.sfhp.org/providers/formulary/pharmacy-therapeutics-committee/


http://www.sfhp.org/files/providers/formulary/Prior_Auth_Criteria.pdf


• PA Criteria

Monograph_Inhaled_steroids

CurrentCriteria_Respiratory_Asthma_COPD

Current_Criteria_Respiratory_Asthma_CS

Proposed_Criteria_Respiratory_Corticoste

3.2_02_Proposed Formulary_Changes_I

Votes: 7 approved, 0 denied, 0 abstained 1st Motion: Roger Tiao, Pharm.D. 2nd Second: Notes: Jenna Heath, PharmD, presented the Inhaled Corticosteroid agents. Topics covered included their place in current clinical guidelines, pharmacology, formulary status, current PA criteria, cost, utilization, PA history, proposed formulary status changes and proposed PA criteria. Ron Ruggiero, Pharm.D. asked if once a day dosed medications cost more than twice a day dosed medications. Per Jenna, the difference is not substantial and the once daily agents are lower compared to some formulations. Jenna Heath, PharmD discussed indicated treatments by age group. Advair requires a PA except for children 4-12 years of age. For children aged 13 who have been getting Advair in the past, there is currently no self-grandfathering in place to allow them to continue treatment with Advair. A prior authorization would have to be submitted if continuation of treatment with Adair is needed. This would be discussed further with PerformRx offline per Dr. James Glauber, MD. Olga Mostovetsky recommended that we increase the quantity limit for Asmanex HFA and other inhaled corticosteroids to 2 units per month rather than the recommended 1unit per month. James Glauber, MD concurred, commenting that it is common for patients to increase their dosage during an exacerbation or cold, so it would be reasonable to allow more than 1 unit per month. Approved changes can be found at the following locations:



3. Acne Medications • Proposed Formulary Changes • PA Criteria

III.A.3 Acne Medications Votes: 7 approved, 0 denied, 0 abstained 1st Motion: Dr. Ron Ruggiero, Pharm.D. 2nd Second:

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ClassReview_Monograph_Acne_Rosacea

Proposed_Formulary_Change_AcneProduc

Current_Criteria_Acne_medications

Proposed_Criteria_Acne_Medications

Notes: Jenna Heath, PharmD, presented the acne agents. Topics covered included place in therapy, clinical guidelines, pharmacology, formulary status, current PA criteria, cost, utilization, PA history, proposed formulary status changes and proposed PA criteria. Concerning current drug pregnancy risk factor ratings, per Ron Ruggiero, PharmD there will be new labeling laws coming into effect to replace the current system. Brad Williams, MD asked if Clindamycin/Benzoyl Peroxide combination products are relatively inexpensive. Per Dr. Jenna, Marks, MD, the combination products are significantly more expensive than using single ingredient products. Approved changes can be found at the following locations:



B) Additional Proposed Changes to SFHP Formulary (Olga Mostovetsky, PharmD, Clinical Pharmacist)- 5 minutes –vote

4.00.01_Proposed Formulary_Changes_V

The P&T Committee reviewed and voted on the following items: III.B. Additional Proposed Changes to SFHP Formulary Votes: 7 approved, 0 denied, 0 abstained 1st Motion: Dr. Brad Williams, MD 2nd Second: Notes: Olga Mostovetsky, Pharm D discussed additional proposed changes to the SFHP formularies. Discussions covered proposed changes for over 10 individual medications (e.g. making memantine immediate release formulary preferred (Tier 1)).. James Glauber, MD inquired if SFHP has received any prior authorization requests for PCSK9 inhibitors. Dr. Olga Mostovetsky, PharmD, responded that there has been no requests were submitted. Approved changes can be found under “Materials”

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section at http://www.sfhp.org/providers/formulary/pharmacy-therapeutics-committee/

****RECONVENE IN OPEN SESSION****

Reconvened to open session around 8:30am.

IV. Summary of Closed Session – 2 minutes (James Glauber MD, CMO)-2 minutes –non voting

Non-Voting item Dr. Ron Ruggiero, Pharm.D. left the room around 8:30am.

V. Annual SFHP Prior Authorization Criteria Review (Olga Mostovetsky PharmD, Clinical Pharmacist and Dai Tan, Pharm.D. Pharmacy Resident)- 40 minutes –vote

6.1_SFHP_Prior_Auth_CriteriaV3.pdf

The P&T Committee reviewed and voted on the following changes: Votes: 7 approved, 0 denied, 0 abstained 1st Motion: Dr. Ruggiero, PharmD 2nd Second: Notes: Olga Mostovetsky, PharmD discussed the annual formulary review process conducted by SFHP in preparation for January P&T. Discussion covered proposed changes for over 30 prior authorization criteria . Ron Ruggiero, Pharm.D. returned at 8:41am (5 minutes into presentation). Olga Mostovetsky, PharmD discussed additional PA criteria updates for several drug classes that were not included in pre-P&T packets (examples include 2nd generation antihistamines, colchicine and enteral nutrition products). Dai Tan, PharmD discussed new criteria developed by SFHP as part of the annual PA criteria review process.

Short-Acting Opiates: James Glauber, MD asked the committee for feedback on duration of approval for short-acting opiates for acute pain. Per Dr. Ruggiero, there has been news regarding high school students from Ohio becoming addicted to opiates and moving onto illicit substances such as heroin after being treated with short acting opiates for sports-related injuries. James Glauber, MD suggested updating the PA criteria to limit the approval period for short-acting opiates for acute pain from 1 year to 3 months. Onychomychosis agents: Dai Tan, Pharm.D. discussed new criteria for onychomychosis agents including the requirement for culture or KOH test positive for fungal infection. James Glauber, MD asked. Brad Williams, MD for feedback on the testing requirement. Per Dr.

52



Williams, he does not employ these tests and treats empirically and relates that empiric treatment is the common standard of care. James Glauber, MD requested removal ofthe requirement for culture or KOH test positive for fungal infection. Brad Williams, MD inquired about the efficacy of Jublia and if the newer agents are comparable to Penlac. Dr. Dai Tan, Pharm.D., the cure rate for newer topical agents is relatively low (10-15%), and similar to Penlac.

Viibryd: Linda Truong, PharmD asked whether a 2-3 month trial period is required for all three preferred agents combined or each preferred agent prior to approval of Viibryd. She emphasized that SSRIs take at least 6-8 weeks to work. SFHP clarified that a 2-3 mont trial of each of the three preferred medications is required. Approved changes can be found at the following locations:

List of updated PA criteria: “Materials” section at http://www.sfhp.org/providers/formulary/pharmacy-therapeutics-committee/


VI. Review and Approval of Interim Formulary Changes and PA criteria and Formulary Placement for New Drugs to Market

(Olga Mostovetsky PharmD, Clinical Pharmacist and Jenna Heath PharmD, Clinical Pharmacist)-15 minutes-vote A) Interim Formulary Changes

Interim_Formulary_Changes_adhoc

2015_12_Interim_Formulary_Changes




B) New Drugs to Market

The P&T Committee reviewed and voted on the following items: Votes: 7 approved, 0 denied, 0 abstained 1st Motion: Dr. Roger Tiao, Pharm.D. 2nd Second: Notes: Olga Mostovetsky, PharmD discussed interim formulary changes that took place prior to January P&T committee meeting which included adding Suprax capsule to formulary and monthly review and formulary placement for new drugs to market and formulary changes needed as a result of drug discontinuations. Jenna Marks, PharmD, highlighted most notable drugs introduced to market since the last meeting. Approved changes can be found under “Materials” section at http://www.sfhp.org/providers/formulary/pharm

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Q1_New_Product_Review

acy-therapeutics-committee/

VII. Follow up discussion from October 2015 P&T Committee Meeting

(Kenneth Garcia, Analyst-Pharmacy Services and Dai Tan-Pharmacy Resident ) – 5 minutes – non-voting

A. Xarelto and Eliquis Utilization

B. Immunization Reports for Individual Clinics

Non-Voting item Notes: Kenneth Garcia, CPhT discussed the increase in utilization of Exjade and Eliquis. There has been a 64% increase in the utilization of Eliquis and a 104% increase in the utilization of Xarelto subsequent to adding these agents to formulary on August 15th 2015. Kenneth Garcia, CPhT asked if the committee wanted to continue monitoring the utilization of these agents. Per committee, no further updates are needed in upcoming P&T meetings regarding Xarelto and Eliquis utilization. In October 2015 meeting, the committee asked if there was a possibility of providing immunization reports to individual clinics regarding their patients receiving immunizations in the pharmacy. As a follow-up, Dai Tan, Pharm.D. stated that currently, SFHP is unable to provide member reports to individual clinics informing them of when their patients receive immunization/s at retail pharmacies. Dai Tan, Pharm.D. discussed other avenues for providers to check immunization history for their patients.

• Surescript (e-prescribing) -this module should display pharmacy claims history per patient.

• California Immunization Registry (CAIR) -state registry that consolidates immunization records into a state wide database. Dai Tan, Pharm.D. stated that although SFHP providers are not required to sign up to this system, it is highly recommended that providers sign-up or register to this module.

Dr. Brad Williams, MD inquired about the formulary status of ZostavaxDai Tan, PharmD, clarified that for members meeting requirementZostavax is covered as a pharmacy benefit without a PA requirement.

VIII. Informational Update on New Developments in the Pharmacy Market – non-voting item

(Jenna Marks, PharmD, Regional Clinical Pharmacist, PerformRx) -5 minutes

Non-voting item: Notes: Jenna Marks, PharmD discussed important pharmacy market developments

54


including Praxbind (Idarucizumab) approval for the reversal of the novel oral anti-coagulant Pradaxa and HCV treatment. Question was raised whether Praxbind should be on pharmacy formulary. This will be researched further and discussed at April 2016 meeting. Linda Truong, PharmD mentioned that there is an Andexanet alfa agent underway for the reversal of Xarelto and other direct Factor Xa inhibitors.

IX. Adjournment

• Next P&T Committee meeting – 2 minutes Wednesday, April 20, 2016

• P&T Committee Member Forms

Non-Voting item Meeting adjourned at 9:25 am Notes: Olga Mostovetsky, PharmD reminded the committee that the next meeting is on April 20th 2016 and that yearly forms are due to be submitted.

The meeting was adjourned at 9:25 AM

Respectfully submitted by:

_____02/05/16______ James Glauber, MD, MPH Date SFHP Chief Medical Officer

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QI-01: Quality Improvement Committee Added:

• Adds the QI Committee member responsibilities for confidentiality and conflicts of interest from QI-02: Quality Improvement Process Confidentiality and Conflict of Interest and retires QI-02.

Updated/Corrected: • Clarifies QI Committee composition, including:

o Membership. o Appointment process. o Representation.

• Clarifies QI Committee operations, including distribution of minutes. • Clarifies QI Committee responsibilities for review and approval of SFHP’s policies and procedures. • Updates “Monitoring” section to reflect current practice.

QI-11: Peer Advisory/Peer Review/and Credentialing Committee Added:

• Adds a “Monitoring” section (moved from the Reporting procedure) to reflect current monitoring practices.

Updated/Clarified: • Clarifies the CMO’s responsibility for committee member selection.

Deleted: • Deletes reference to QI-02: Confidentiality and Conflict of Interest, which is retired and combined with

QI-01: Quality Improvement Committee. Pharm-08: Pharmacy Formulary, Prior Authorization Criteria, and Policy Annual Review (Annual Update) Updated/Corrected:

• Updates procedure for formulary changes. • Updates procedure for new drugs to market and market changes to existing drugs. • Updates “Monitoring” section to reflect current practice.

Pharm-09: Pharmacy Formulary, Prior Authorization Criteria, and Policy Annual Review (Annual Update) Updated/Corrected:

• Updates “Monitoring” section to reflect current practice.

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SFHP POLICY AND PROCEDURE

Quality Improvement Committee Policy and Procedure number:

QI-01

Department Owner: Health Improvement Lines of Business Affected: n/a

POLICY STATEMENT The SFHP Quality Improvement Committee (QIC) is a committee of the San Francisco Health Plan (SFHP) Governing Board. QIC is responsible for reviewing and approving the annual QI Work Plan and Evaluation, and for providing oversight of the SFHP’s quality improvement program activities. QIC is the main forum for member and provider participation in assuring the quality of SFHP’s care delivery system.

PROCEDURE I. COMMITTEE COMPOSITION The Quality Improvement Committee has a minimum of 10 members and a maximum of 18 members. A minimum of two seats are held by members of the Member Advisory Committee; one seat will be held by a labor representative. All other seats would be filled by persons with relevant experience to be nominated by the Chief Medical Officer (CMO) and approved by the Governing Board. 1. The CMO and members of the QIC nominate individuals with relevant experience. 2. One committee member must be able to provide expertise in behavioral health services. 3. The SFHP CMO is responsible to make a specialty physician available to the assist the QI Committee

in its activities when needed. 4. The CMO will select and brief a physician consultant whenever the need arises. 5. Members are appointed for two-year terms and may be reappointed. The CMO also has the option of

automatic renewal of membership. Terms begin on January 15th of each year. 6. The Governing Board approves all members nominated to the committee. 7. SFHP makes the utmost effortstrives to secure attendance of at least one (1) physician

representative from each of SFHP’s medical groups at all committee meetings. 6.8. II. COMMITTEE OPERATIONS 1. QI Committee meetings will be held at least four times a year. 2. A quorum is five members with three physician members present. 3. A simple majority of those present makes decisions. 4. Meetings are conducted using Robert's Rules of Order. 5. The SFHP CMO is responsible for the completion of accurate QI Committee meeting minutes. All

minutes are maintained for seven years as required by contract. Any applicable substantiating data is appended for reporting purposes. Minutes of the previous meeting are approved as the first agenda item of the QI Committee meeting. Once approved by majority vote, the SFHP CMO forwards copies of the minutes to committee members. The Chief Compliance oOfficer ensures copies of the minutes are received by, the Chief Executive Officer, Governing Board, and the California Department of Health Services.

57

6. The committee is governed by a Confidentiality and Conflict of Interest procedure as described in section IV., below.

6. A Confidentiality and Conflict of Interest Policy governs the committee’s proceedings. III. RESPONSIBILITIES include, but are not limited to: 1. Annually review, modify and approve the Quality Improvement (QI) and Utilization Management (UM)

Program descriptions. 2. Annually review, modify and approve the QI and UM Evaluations and Work Plans. 3. Annually review, modify and approve the Credentialing Program, policies and procedures. 4. Make recommendations and approve medical policy and protocol changes based on guidelines and

standards of practice. 5. Approve clinical criteria and clinical practice guidelines used in utilization management decisions. 6. Provide medical opinion regarding technological advances in consideration of benefit enhancements,

inclusions, and exclusions. 7. Recommend and approve preventive health guidelines. 8. Make recommendations and approve the Health Services Department’s policies and procedures

directly impacting the provider network or SFHP members or per discretion of the CMO for quality improvement, utilization management, case management, care coordination, and care transitions, provider relations and pharmacy services.

9. Make recommendations on quality initiatives as they apply to members and providers. 10. Evaluate the implementation of the QI Work Plan and update it based on its quarterly review of data

and the results of studies, audits and other QI activities. 11. Address specific cases of non-compliance with Plan policies or regulatory standards and assure

appropriate corrective actions are taken. 12. Submit reports of its activities to the Governing Board through meeting minutes. IV. CONFIDENTIALITY AND CONFLICTS OF INTEREST Documents created as part of the quality improvement (QI) process that contain identifiable member or provider information are confidential and are maintained according to the requirements of HIPAA, the Knox-Keene Health Plan Act, the San Francisco Health Plan’s (SFHP) Employee Handbook, and related documents. These documents include, but are not limited to, peer review information, patient care review studies, quality improvement studies and reports, minutes of quality improvement and other committee meetings and administrative (i.e., non-clerical) processes. Quality Improvement Committee members and participants must sign the SFHP Confidentiality and Conflict of Interest Statement. SFHP employees participating in Quality Improvement Committee meetings must sign the SFHP Employee Handbook Confidentiality Statement. Strong efforts are made to avoid participation in quality improvement activities when a conflict of interest may impact fair decision-making. 1. The SFHP Chief Medical Officer (CMO) orients members of all quality improvement committees to

SFHP confidentiality and conflict of interest policy. Each committee member and participant signs SFHP’s Confidentiality and Conflict of Interest Statement.

2. All quality improvement documents are marked confidential and are distributed with all member and provider names censored. Sensitive materials distributed at meetings are collected and maintained in a secure location at the Plan that is accessible only to the CMO and the Director of Health Improvement.

3. The committee chair is responsible for identifying any QI committee agenda topics or issues that may introduce a potential conflict of interest with committee members or staff. Agendas will be distributed to committee members prior to the meeting for identification of possible conflicts. Members are required to disclose conflicts of interest.

4. When there is a conflict of interest identified, the CMO may request that a committee member refrain from voting and or attending the discussion. If the committee member disapproves of the request, the member may request an informal hearing before the committee. The committee makes the final determination on the presence or absence of a conflict of interest. The decision is recorded in the committee meeting minutes.

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REPORTING IMPROPER DISCLOSURE OF PATIENT HEALTH INFORMATION (“PHI”) OR

SUSPECTED BREACH OF SECURITY Disclosure: Per contract with the California Department of Health Care Services (DHCS), SFHP will

notify the DHCS Contract Officer within twenty-four (24) hours during a work week of any improper disclosure of PHI, whether intentional or accidental.

Security Breach: SFHP will notify the DHCS Contract Officer within twenty-four (24) hours of any suspected or actual breach of security, intrusion or unauthorized disclosure that compromises the privacy and protection of PHI.

MONITORING The QI Committee meets at least quarterly. Agendas and meeting minutes are stored onsite at SFHP, on SFHP’s secure server, and posted to SFHP’s public website. As required by the Brown Act (CA Government Code §§54950, et seq.), the agenda is sent as public notice to the San Francisco Public Library at least 72 hours prior to each meeting. Meeting minutes are provided to the Chief Executive Officer, SFHP Governing Board members, and the California Department of Health Services.

DEFINITIONS None

AFFECTED DEPARTMENTS/PARTIES Health Improvement Provider Relations Clinical Operations Complex Medical Case Management Pharmacy Services Governing Board

RELATED POLICIES AND PROCEDURES AND OTHER RELATED DOCUMENTS Quality Improvement Program Description

REVISION HISTORY Effective Date: November 30, 2005 Approval Date: February 7, 2008, March 7, 2011 Revision Date(s): November 30, 2005, January 18, 2008, February 3,

2011, December 8, 2011, January 6, 2014, February 3, 2016

REFERENCES CDHCS/SFHP contract, Exhibit A, Attachment 4, Sections 2-4 CCR Title 28, CCR §Section 1300.70

59


Physician Advisory/Peer Review/and Credentialing Committee Policy and Procedure number:

QI-11

Department Owner: Health Improvement Lines of Business Affected: n/a

POLICY STATEMENT The purpose of the SFHP Physician Advisory/Peer Review/Credentialing Committee (PAC) is threefold: 1. To create a forum for network physicians to provide comment and recommendations to SFHP on

standards of care, clinical programs and guidelines and quality initiatives; 2. To serve as the Peer Review Committee to address concerns or identified problems related to issues

of quality of medical care; and 3. To review credentials and approve practitioners for participation in the SFHP network and review the

credentialing policies and activities of entities delegated for credentialing.

PROCEDURE

I. COMMITTEE STRUCTURE: The committee is chaired by the SFHP Chief Medical Officer (CMO) or physician designee (MD) and is composed of physicians from SFHP contracted medical groups and facilities, including the University of California Medical Center, San Francisco Community Clinic Consortium (SFCCC) clinics, and the Department of Public Health (DPH). Physician representatives from all medical groups and specialty areas are invited to serve as ad-hoc members to discuss clinical programs and issues as they arise. SFHP makes the utmost effort to secure attendance of at least one (1) physician representative from each of SFHP’s medical groups at all committee meetings.

Members are nominated and selected by the SFHP CMO, Associate Medical Director, and SFHP senior staff. The term of membership is two (2) years with the option of automatic renewal at the discretion of the CMO. While committee membership is limited to three (3) terms, the CMO or Associate Medical Director may waive this restriction for specific members on an as-needed, case-by-case basis. Meetings are held quarterly and held at least four (4) times a year.

II. STIPEND: A stipend of $150 for attending the meetings will be provided to each physician who

attends.

III. QUORUM: For Peer Review and Credentialing activities, quorum consists of three (3) voting physician members; a simple majority of those present carries a decision. The committee chair is a voting member. Physician Advisory activities, in contrast, do not require quorum for discussion.

IV. REPORTING: The committee submits minutes of each meeting and a report, which is part of the

Annual Quality Improvement and Utilization Management (QI/UM) Evaluation to the Quality Improvement Committee (QIC), which reports to the Governing Board.

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V.IV. RESPONSIBILITIES A. In the capacity of clinical advisors, the committee:

1. Reviews and makes recommendations for corrective action based upon other committee reports including: QIC, Pharmacy and Therapeutics (P&T) Committee, and PA/PR/Credentialing Committee.

2. Reviews and makes recommendations for corrective action based upon medical oversight of delegated functions.

B. In the capacity of the Peer Review Committee (closed session), the committee:

1. Reviews internally identified potential quality issues (PQI), including provider preventable conditions (PPC), and related research for providers who are potentially subject to medical disciplinary cause or action that could alter the provider’s current or proposed participation in the SFHP network. a. The Peer Review committee ensures that the contracting organization researches

and evaluates the actions leading to the PQI and responds appropriately to the findings.

2. Assigns levels to describe the severity and impact of the case. 3. Makes recommendations for future actions.

C. In the capacity of the Credentialing Committee (closed session), the committee:

1. Approves Credentialing and Recredentialing Program and all policies and procedures related to credentialing.

2. Reviews and approve all SFHP credentialed and recredentialed practitioners. 3. Reviews and make decisions regarding practitioners with an open accusation with the

Medical Board of California. 4. Reviews and make decisions regarding practitioners with quality of care case. 5. Reviews terminations of practitioners deemed by the Department of Health Care Services

(DHCS) or the Office of Inspector’s General (OIG) as ineligible to participate in the Medi-Cal program.

6. Reviews quarterly credentialing reports from delegates 7. Reviews credentialing audit findings from the delegated groups. When credentialing is

delegated, the Peer Review Committee retains the right to review and overturn the credentialing decisions of the delegate.

8. Reviews the annual facility site review and medical record review reports.

MONITORING The CommitteePAC meets at least quarterly. Agendas and meeting minutes are stored onsite at SFHP, on SFHP’s secure server, Meeting minutes are provided to DHCS at the annual audit.

DEFINITIONS Provider Preventable Conditions (PPC) — As defined by federal regulations, PPCs are health-care acquired conditions (HCAC) in inpatient hospital settings as well as other provider-preventable conditions (OPPC) in all healthcare settings.

AFFECTED DEPARTMENTS/PARTIES Provider Relations Health Improvement Utilization ManagementClinical Operations Compliance and Regulatory Affairs

61

RELATED POLICIES AND PROCEDURES AND OTHER RELATED DOCUMENTS QI-01 Quality Improvement Committee PR-01 Credentialing and Recredentialing Program PR-10 Facility Site Review and Medical Record Review PR-04 Peer Review Process QI-02 Confidentiality and Conflict of Interest PR-12 Oversight of Functions Delegated Functions

REVISION HISTORY Effective Date: July 1, 2006 Approval Date: August 20, 2007, December 30, 2010, October 9, 2014 Revision Date(s): July 7, 2007, November 16, 2010, November 20, 2012, July 10,

2014, October 3, 2014, February 3, 2016

REFERENCES 1. 22 CCR §53860 2. 28 CCR §1300.70 3. DHCS/SFHP Contract Exhibit A, Attachment 4, Provision 12; Exhibit A, Attachment 18, Provision 4M 4. List of Provider-Preventable Conditions: http://files.medi-

cal.ca.gov/pubsdoco/newsroom/newsroom_20473.asp

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http://files.medi-cal.ca.gov/pubsdoco/newsroom/newsroom_20473.asp

http://files.medi-cal.ca.gov/pubsdoco/newsroom/newsroom_20473.asp

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Pharmacy Formulary, Prior Authorization Criteria, and Policy Annual Review Policy and Procedure number:

Pharm-08

Department Owner: Pharmacy Services Lines of Business Affected: Medi-Cal, Healthy Kids

POLICY STATEMENT San Francisco Health Plan (SFHP) will conducts an annual review and update for all of the following: (1.) Fformulary list of preferred, prior authorization required, and non-formulary, and excluded

medications; , (2.) Pprior authorization criteria provided to the Pharmacy Benefits Managed (PBM) to be used in

reviewing prior authorization requests;, and (3.) p Pharmacy polices.

PROCEDURE 1. SFHP Pharmacy Services department maintains a working formulary list of preferred, prior

authorization required, non-formulary, and excluded medications for Medi-Cal, Medicare/Medi-Cal, Healthy Kids, and Healthy San Francisco lines of business. The designated formulary status, formulary restrictions (e.g. , quantity limits, age edits, gender edits) and any step therapy requirements will be reviewed annually and updated annually updated to reflect any market updates or changesand/or clinical practice changes. All pProposed changes will be presentedare presented to the SFHP Pharmacy and Therapeutics Committee and must be approved by a quorum vote before being implemented. Updated The updated formulary will then beis submitted annually to the Department of Health Care Services for review and approval. Additional changes to the SFHP formulary will beare made as part of ongoing drug class reviews, which occur at quarterly Pharmacy and Therapeutics Committee meetings.

2. SFHP Pharmacy Services department maintains pharmacy prior authorization criteria to assist in

pharmacy prior authorization request decision review. This will be Criteria will beare reviewed and updated annually as necessary and during as part of ongoing drug class reviews, which occur at quarterly SFHP Pharmacy and Therapeutics Committee meetings.

3. New drugs to market or market changes to existing products drugs will beare reviewed monthly and

formulary placement will beis updated as necessary as an interim formulary change by recommendations provided by the PBM’s clinical services team. These iInterim formulary changes will are presented to the at the quarterly SFHP Pharmacy and Therapeutics Committee meetings and must be approved by a quorum vote at the following meeting.

4. SFHP Pharmacy services will maintains pharmacy policies, and reviews and updates all pharmacy

policies annually.

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5. SFHP Pharmacy services will reviews all applicable policies and procedures from its vendors

annually.

MONITORING

1. Changes to formulary status, formulary restrictions, and prior authorization criteria recommended as part of drug class reviews will beare presented at quarterly SFHP Pharmacy and Therapeutics Committee meetings and documented in meeting minutes.

2. Monthly interim changes to SFHP formulary will beare presented at quarterly SFHP Pharmacy and Therapeutics Committee meetings and documented in meeting minutes.

3. Annual changes to 1. SFHP receives and reviews formulary documents from the PBM summarizing all current coding. SFHP’s formulary and formulary restrictions willare presented annually at October SFHP Pharmacy and Therapeutics Committee meetings and documented in meeting minutes.

Annual changes to SFHP prior authorization criteria will beare presented at January SFHP P&T Committee Meeting and documented in meeting minutes.

1.4. 2. 2. The PBM will provide monthly drug updates.

DEFINITIONS None

AFFECTED DEPARTMENTS/PARTIES Pharmacy Services Pharmacy and Therapeutics Committee

RELATED POLICIES AND PROCEDURES AND OTHER RELATED DOCUMENTS 1. Pharm-01 Pharmacy and Therapeutics Committee 2. Pharm-02 Pharmacy Prior Authorization

REVISION HISTORY Effective Date: December 2013 Approval Date: December 12, 2013 Revision Date(s): February 3, 2016

REFERENCES NCQA Standard UM 13 Procedures for Pharmaceutical Management

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Pharmaceutical Patient Safety Policy and Procedure number:

Pharm-09

Department Owner: Pharmacy Services Lines of Business Affected: Medi-Cal, Healthy Kids

POLICY STATEMENT San Francisco Health Plan (SFHP) pharmacy department maintains protocols to ensure the expedited process for prompt identification and notification of members and prescribing practitioners affected by Class II recall or voluntary drug withdrawals for safety reasons and Class I recalls.

PROCEDURE SFHP has procedures for Class I, Class II, and voluntary drug withdrawals from the market for safety reasons. SFHP works with its Pharmacy Benefits Manager (PBM), who will would identify members and prescribing practitioners who are affected by a drug recall. SFHP will would notify the affected member s and their prescribing physicians by phone and/or mail within thirty (30) day calendar days of the Food and Drug Administration (FDA) notification of Class II recalls and voluntary recalls for safety reasons. SFHP will would notify the affected members and their prescribing physicians by phone and/or mail within twenty-four (24) business hours of notification by the PBM for Class I recalls. Procedure: Class I Recall:

1. The PBM will monitors FDA Recalls, Market Withdrawals and Safety Alerts website, http://www.fda.gov/opacom/7alerts.html, daily and provides SFHP complete recall information monthly via the Monthly Drug Update.

2. The PBM will undergo undertakes a prompt review of all pharmacy claims data to identify prescribing practitioners who have written prescriptions for the recalled medication and members who have received the recalled medication within the last six (6) months.

3. The PBM will sends a description of the medication recall and list of affected members and prescribing practitioners within five (5) business days of the recall to SFHP. The PBM will also sends a description of the medication recall to all network pharmacies via fax blast.

4. SFHP will notify notifies affected members and their prescribing physicians by phone and/or mail within twenty-four (24) business hours of notification by the PBM for Class I recalls.

Class II Recall, Market Withdrawals and Safety Alerts:

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http://www.fda.gov/opacom/7alerts.html

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1. The PBM will monitors FDA Recalls, Market Withdrawals and Safety Alerts website, http://www.fda.gov/opacom/7alerts.html, daily and provide SFHP complete recall information monthly via the monthly Drug Information Update located on website portal.

2. The PBM will undergo undertakes a prompt review of all pharmacy claims data to identify prescribing practitioners who have written prescriptions for the recalled medication and members who have received the recalled medication within the last six (6) months.

3. The PBM will sends a description of the medication recall and list of affected members and prescribing practitioners within ten (10) business days of the recall to SFHP. The PBM will also sends a description of the medication recall to all network pharmacies via fax blast.

4. SFHP will notify notifies the affected member s and their prescribing physicians by phone and/or mail within thirty (30) day calendar days of the FDA notification of Class II recalls and voluntary recalls for safety reasons.

Exceptions: 1. Withdrawals unrelated to safety issues 2. Recalled or withdrawn pharmaceuticals for which the organization is unable to identify affected

members from the batch of lot numbers 3. Wholesale-only drug recalls and withdrawals

MONITORING 1. SFHP receives and reviews formulary documents quarterly from PBM summarizing all current coding. 2. The PBM will provide monthly drug updates via website portal. Relevant drug recall information and actions taken by SFHP will beare presented at quarterly SFHP Pharmacy and Therapeutics Committee meetings and documented in meeting minutes.

DEFINITIONS Class I recall – A situation in which there is a reasonable probability that use of or exposure to a product will cause serious adverse health consequences or death Class II recall – A situation in which use of or exposure to a product may cause temporary or medical reversible adverse health consequences or where the probability of serious adverse health consequences is remote. Market Withdrawal – A firm’s removal or correction of a distributed product that involves a minor violation which would not be subject to legal action by the FDA.

AFFECTED DEPARTMENTS/PARTIES Pharmacy Services Pharmacy Benefit Manager

RELATED POLICIES AND PROCEDURES AND OTHER RELATED DOCUMENTS

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http://www.fda.gov/opacom/7alerts.html

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PerformRx Policy PTFD-2-08 – Drug Recall Notifications

REVISION HISTORY Effective Date: December 2013 Approval Date: December 12, 2013 Revision Date(s): February 3, 2015

REFERENCES NCQA Standard UM 13 Procedures for Pharmaceutical Management

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San Francisco Health Plan Utilization Management Committee Tuesday, December 15, 2015 3:30 pm to 5:00pm, Excelsior Conference Rm.

Meeting called by: Collin Elane

Type of meeting: Monthly Meeting Recorder: Maika

Attendees: Glauber, James; McDonald, Kirk; Elane, Collin; Cale, Matija; Donald, Fiona; Hefflefinger, Maika; Tai, Tony; Baldzikowski, Monica; Au, Rebecca; Nguyen, Kendrix; Ratnesar, Dr. Rajendra; Mostovestsky, Olga; Custodio, Ralph; Absent:

Topic Brought By Time Discussion Action

1. Review: Action items

Collin/All 3:30-3:45 • Action Items from 11/17/2015

2. Standing Agenda: Overturned Appeals

Collin 3:45-4:00 • Discuss o UM o Rx

• Recommendations

3. Discussion: Delegation Oversight Audit Results

Ralph/Kirk 4:00-4:15 • Utilization Management Audit Results • Case Management and Coordination of Care Audit Results • Next Steps

4. Update: UM Reports Review

Collin 4:15-4:30 • Medical Supplies • UM Trending Report • Approved/Denied Auth Summary

5. Discuss: Denial Rates for SFHP/DMG

Collin/Jim 4:30-4:45 • Compare and discuss UM rates by service • Next Steps for PA Policy/PPI

January UMC will focus on services identified in Pre-Auth list

6. Proposal: Max Units on Referrals

Monica/Collin 4:45-4:50 • UM-19 Proposal • Max Units

7. Review: Next Steps/Action Item Review

Maika 4:50-4:55 Action Items

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http://teams/medman/UM%20Committee/Forms/AllItems.aspx?RootFolder=%2Fmedman%2FUM%20Committee%2F2015%2F12-December-2015%2FMeeting%20Materials&FolderCTID=0x0120005EC87A45938CB247A1E177C6968A0586&View=%7B2D9FE992-6FE0-4580-9FB2-31C58E74259F%7D&InitialTabId=Ribbon%2ELibrary&VisibilityContext=WSSTabPersistence

http://teams.sfhp.org/medman/UM%20Committee/2015/12-December-2015/Meeting%20Materials/DMG

http://teams.sfhp.org/medman/UM%20Committee/2015/12-December-2015/Meeting%20Materials/Reports

http://teams.sfhp.org/medman/UM%20Committee/2015/12-December-2015/Meeting%20Materials/Utilization%20Report



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ACTION ITEMS: ITEM

# OWNER ACTION ITEMS STATUS

1. Monica • (12/15/15) If we are going to approve the glucose monitor, we should also approve the strips. Monica will follow-up with Rebecca.

• (11/17/15) Patty and Monica will add changes into the SFHP Criteria Transgender Services document from the THS discussion yesterday, and send a summary of the changes along with the edited document to UMC members to evote. Please include bullet points that have changed at the top.

• (10/26/15) Monica will follow-up to see if we have access to data for stratification by Type 1 as well as check HEDIS Data; talk to Raj whether or not he will approve or deny these cases. (Any updates?)

• • Patty, Fiona, and Monica met and it took a

couple meetings to decide on how to stylistically format it. Patty completed section 1 and section 2 is in progress. Everything but genital surgery is included in section 2. Facial plastic surgery vs. genital surgeries have different UM processes. This document will be completed after the new year.

• Sari confirmed there is no data, but we can put in a request to Jose. Continuous Glucose monitoring is an excluded benefit, and we wanted to get the number of people within the plan with Type I Diabetes. Monica will continue to look into data. We might have to do one-offs until a DHCS decision has been made.

3. Ralph • (12/15/15) Ralph to follow-up with Odalis to find out how the pharmacy audit went with Kaiser.

•

•

4. Collin • (12/15/15) Collin will ask Jose for denial rates by medical directors. • (11/17/15) Collin to discuss with Jim the role the quality review nurse will take on

for reviewing Pharmacy items.

• In Process • Deferred until additional resources hired

5. Rebecca • (12/15/15) From the Cimzia appeal that was resolved on 11/19/15, Fiona and Rebecca will discuss Anti-TNF criteria– 6 months vs. 12 months approvals.

•

6. Fiona • (12/15/15) From the Cimzia appeal that was resolved on 11/19/15, Fiona and Rebecca will discuss Anti-TNF criteria– 6 months vs. 12 months approvals.

• (12/15/15) Fiona will review the additional information for the Viekira Pak overturned appeal that was reviewed by Dr. Raj and resolved on 11/19/15. Perhaps we would like to incorporate the additional information and the quoted guidelines from AASLD/IDSA into our PA policy.

•

PARKING LOT: ID# ITEM DATE LOGGED STATUS

1. Continue PBM/Contracts action item to continue to dig up and figure out how much effort we would like to put into this. We are more concerned with the onesie and twosies. Lisa has been working with Russ in PNO to help fix this issue. We 12/15/15 Follow-up in

Feb. 2016

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have looped back, but the work still needs to get completed. There are a number of LTC claims going through pharmacy and it has been found to be an inappropriate benefit. Laguna Honda is a little more complicated to set rates for non-CHN and CHN members.

2. Determine long-term solution for requesting visits for specialty care OOMG. • Create a long-term solution either by creating new processes. • Create a new process in UM or fold this into a new ANG process.

12/15/15 Continue follow-up for 2016

DECISIONS

ID# ITEM DATE LOGGED

1. Decided to take on a short-term recommendation for increasing the number of units on specialty office visits OOMG (UM-19) 12/15/15

2. When we identify delegated issues, we will send to Ralph. 11/17/15 3. Compliance Clin Ops CMO File Review will be called Denial File Audits. 11/17/15

Meeting Notes from Tuesday, 12/15/15: ITEM


1. Monica • (11/17/15) Patty and Monica will add changes into the SFHP Criteria Transgender Services document from the THS discussion yesterday, and send a summary of the changes along with the edited document to UMC members to evote. Please include bullet points that have changed at the top.

• (10/26/15) Discuss with Fiona to look at Photodynamic Therapy in Hayes. (Done) • (10/26/15) Monica will follow-up to see if we have access to data for stratification

by Type 1 as well as check HEDIS Data; talk to Raj whether or not he will approve or deny these cases.

• Patty, Fiona, and Monica met and it took a couple meetings to decide on how to stylistically format it. Patty completed section 1 and section 2 is in progress. Everything but genital surgey is included in section 2. Facial plastic surgey vs. genital surgeries have different UM processes. This document will be completed after the new year.

• Looked in Hayes and is a B-rating. • Sari confirmed there is no data, but we can

put in a request to JJ. Continuous Glucose monitoring is an excluded benefit, and we wanted to get the number of people within the plan with Type I Diabetes.

• Monica will continue to look into dataWe might have to do one-offs until a DHCS decision has been made.

2. Matija • (08/15/15) Continue PBM/Contracts action item to continue to dig up and figure out how much effort we would like to put into this. We are more concerned with the onesie and twosies. (Move to Parking Lot – reassigned to Lisa; Feb. 1st follow-up)

• Matija will follow-up with Lisa. Matija sent Lisa an e-mail, Lisa is now working with Russ in PNO to help fix this issue. Kudos to Jackie P. for discovering the leakage.

• We have looped back, but the work still

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needs to get completed. There are anumber of LTC claims going through pharmacy and it has been found to be an inappropriate benefit. Laguna Honda is a little more complicated to set rates for non-CHN and CHN members.

4. Patty • (11/17/15) Patty will add facial plastic reconstructive procedures on page 1. NOA

language modification. • (11/17/15) Patty and Monica will add changes into the SFHP Criteria Transgender

Services document from THS discussion yesterday, and send a summary of changes and the edited document to UMC members to evote. Include bullet points that have changed at the top.

• Complete!

1. Ralph • (11/17/15) Ralph to follow-up with Odalis on when she will submit DNOC minutes to QIC. Complete!

• Complete!

2. Collin/Jim • (11/17/15) Collin to discuss with Jim the role the quality review nurse will take on for reviewing Pharmacy items.

• In Process (Collin)

3. Rebecca • Add Enteral Nutrition Criteria to the agenda for January P&T. • Complete! 4. Fiona • Look at Photodynamic Therapy in Hayes. • Complete!


3. Continue PBM/Contracts action item to continue to dig up and figure out how much effort we would like to put into this. We are more concerned with the onesie and twosies. 12/15/15 Follow-up in

Feb. 2016 4. DECISIONS

ID# ITEM DATE LOGGED 1. When we identify delegated issues, we will send to Ralph. 11/17/15 2. Compliance Clin Ops CMO File Review will be called Denial File Audits. 11/17/15

Overturned Appeals

UM • There were 3 cases for glucose monitoring in August.

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o Continuous blood glucose monitoring – we overturned due to additional information that was provided. Originally the submitted procedural code was not covered by Medi-Cal.

Resolution: we reviewed under New Hayes Criteria; it was recommended that we cover this and we are waiting to make final decision. We plan to approve by exception.

o Action Item: Monica will follow-up with Rebecca on whether we should approve strips if we are going to approve glucose monitors. Pharmacy • Lidocaine Hydrochloride Jelly – Patient reimbursement originally denied due to the quanity limit for Licodaine Hydrochloride Jelly. Recently SFHP changed their

formulary for this medication to not have a quanity limit, and has sent the patient a reimbursement. • Cimzia- Appealed for 12 month supply instead of 6 months. This was originally denied due to not taking other recommended alternatives. Appeal was overturned

with the submission of clinical documentation that noted a good clinical reponse to Cimzia relative to Humira. o Action Item: Fiona and Rebecca will discuss 6 month vs. 12 month approvals for Anti-TNF criteria.

• Veregen – Originally denied since non-formulary medicine cannot be covered unless preferred medicines have been used. This appeal was overturned due to additional information in the form of two journal articles submitted by the patient’s physician. Denial language has been changed for this request.

• Viekira – Original request did not meet criteria for DHCS Treatment Policy. Approved due to additional information that met DHCS requirements; elevated RHS factor is sufficient?

o Action Item: Fiona will review the additional information that led to the overturn and we can decide if we want to incorporate that into our PA policy. • Ensure – Appealed due to additional information stating poor dentition and lack of access to food. Additionally, there was more information to your chronic

diagnosis. o Action Item: Monica will look at Enteral Criteria and make sure that HIV wasting was included

Delegation Oversight Audit Results Utilization Management Audit Results All of the delegated medical group (DMG) audits are completed. We issued all of the audit scores and whether a DMG required a CAP.

• Kaiser scored 100% on 20 P&P factors out of 20; no CAP required. • HILL scored 100% on 19 P&P factors out of 20, 1 CAP was issued:

o The factor with a CAP – UM 3 Element A: Access to staff. o A CAP was issued because Hill’s P&P neglected to include this requirement.

• CCHCA scored 100% on 17 P&P factors out of 20; 3 CAPs were issued: o UM 2: Element C: Consistency in Applying Criteria o UM 4 Element A: Licensed Health Professionals o UM 4 Element E: Use of Board-Certified Consultants

• Brown & Toland scored 100% on 12 factors out of 20, scored 86-95% on 6 factors, and received 2 CAPs on file review factors. o They received a 65%, or below, in the area of Timeliness of Non-Behavioral Healthcare UM Decision Making and Reason for Non-behavioral

Healthcare Denial. When a CAP is issued, SFHP emphasizes the DMG is not being reprimanded. A CAP is an opportunity to improve how delegated responsibilities are carried out. SFHP’s role is to work collaboratively with a DMG to assist in correcting the CAP. Currently, SFHP is collaboratively assisting the various delegated medical groups to strengthen their policy and procedures and turn-around-time (TAT) processes and practices. Action Item: Ralph to follow-up with Odalis to find out how the pharmacy audit went with Kaiser.

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Case Management and Coordination of Care Audit Results

Brown & Toland had 1 P&P category at 100%, 2 P&P’s in the 90th percentile, and 4 categories below 75% that received CAPS. The documentation for communication was difficult for many individuals. The member perspective was missing in terms of how members were affected in this area. CCHCA had 1 category that reached 100% and 4 categories that received CAPs. They similarly fell short in communication. Hill had 4 categories that received a CAP’s. NEMS had 4 categories receiving CAP’s. They do not have the capacity to include a member perspective. Kaiser did not submit any documentation. SFHP met with them today and Kaiser made a commitment to one general library across the board. Again, it’s emphasized that they are doing this, but documentation is lacking.

Improvement can be seen across the medical groups in the elements: Comprehensive and Complex Case, Coordination of Care with all provider types, CCS/ES/GGRC/CHDP/LEA/ Children with Special Health Care Needs (CSHCN), and Transition of Care/Access and Availability.

NEMS needs to state that they have the capacity to support Health at Homes in their documentation.

UM Reports Review

Medical Supplies Earlier this year we decided to expand the units of medical supplies to include a year. Tony did the research on maximum units. Tony runs this report quarterly. We pay 30% of bill charges. We will continue to monitor this every quarter and will bring back to Utilization Management Committee (UMC) if any changes were created. UM Trending Report We are redirecting our providers from OOMG and IMG. A lot of work that we do is based on configuration and our inability to determine what’s OOMG and IMG in our contracts. Currently, we have a two-year timeline for this overhaul in reconfigurations to our systems. Metrics include Total Bed Days, Acute Admits, etc. We are seeing a downward trend in SPD for total bed days. One of those noteworthy interventions has been the CareSupport program. We are planning to refine the data on yearly members without visits. We are seeing the effect of Medi-Cal expansion in this graph. We are seeing a 7% increase in physician utilization as a result of the auto-assignments due to the Medi-Cal expansion. We are seeing a downward trend in outpatient visits due to a decrease in specialty visits. One of the primary observations is the large increase in the percent expansion of members without visits versus the percent non-expansion of members without visits. If you look at the ratio of PCP to Specialty, NEMS has a very high ratio (6:1). Readmissions Rate is 1:2. CHN recommended case management as a PIP measure in 2016. Denial Rates for SFHP/DMG We have a report for inpatient and prior authorizations. PA’s have been pretty stable. We see a downward trend in denied outpatient and DMEPOS authorizations.

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In January, we will take a look at the services we are approving and denying. We already determined which services are no brainers and have a low denial rate. Monica proposes that we should take a look at the list on the website of services we approve. We should update the list and make sure our decisions are aligning with this. Monica’s team is doing a lot of work so that services aren’t being denied due to last year’s audit. The team is minimizing possible denials by making sure the right codes are used or connecting them to a PCP. The Inpatient Concurrent Review showed the total days that were requested and denied. Some of these denials was due to the lack of documentation or delay in notification, causing a high denial rate in this graph. In September when we transitioned to IP to IP, we didn’t see a noticeable decrease in care days denied. Action: Collin will ask Jose for denial rates by medical directors. UM - 19 There is a gap between what the contract says and what we are doing. Monica has a short-term and long-term recommendation.

A) No authorization is required once the standing referral to specialty care is approved. B) Specialist can act as the PCP when it’s in the best medical interest of the member. C) TAT for standing referral to specialty care. D) If the provider is available in-network/in-medical group, then requirement is met.

The second gap exists in SFHP’s process for a member or provider to request a standing referral to specialty care. Perhaps, we can discuss a plan in the next year to address that gap. Short-term Recommendation Increase the number of visits for specialty visits OOMG. We would for example authorize 12 office visits for OOMG. We would like to do this so that we don’t create a barrier for those people who request a specialty OOMG. We could implement this right away by changing the maximum office visits by a member. Decided to take on a short-term recommendation for increasing the number of units on specialty office visits OOMG. Parking Lot Action Item: Long-term solution (TBD) Long-term Recommendation: Create a long-term solution either by creating new processes. Create a new process in UM or fold this into a new ANG process. Max Units on Referrals A Dec. 1st launch of Phase I is the goal. We will start with the CPMC pilot. The rationale for choosing to start with CPMC is that we have access to their EHR. We will do a trial/roll-out phone call in the next week. The difference between Consortium and SFHN is that we don’t have access to their universal PCP line.

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There is a centralized system for post-discharge referrals. As of 12/1 the focus will be post-discharge and in mid-December, we will assess the data. SFHN can perhaps adopt this system for specialty referrals. Next Steps for UMC Discussion We are finishing up the year. Next year, we will continue with the standing items on the agenda. QNXT upgrade is now complete so a lot of QNXT configurations that were put on hold can be pushed through now. There were items discussed in the past 6 months where we were considering removal of medical necessity. Monica’s has a concern for using denial rates to change criteria. She would prefer to go through changes by service and what’s on our website. She thinks it’s good to look at the PA list of what requires medical necessity and then go through them to decide if we would like to have changes to the configuration. Patty mentions that it would be nice to do measurements of the process implemented at SFGH for specialty referrals, and watch that balance of in-medical group vs. OOMG. The QNXT team will have an outside consulting group coming in to do in-house interviews. They will take a look at how we currently configure PA’s and make recommendations on we can improve them.

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San Francisco Health Plan Utilization Management Committee Wednesday, January 27, 2016 3:00 pm to 5:00pm, Excelsior Conference Rm.

Meeting called by: Collin Elane

Type of meeting: Monthly Meeting Recorder: Maika

Attendees: Glauber, James; McDonald, Kirk; Elane, Collin; Cale, Matija; Donald, Fiona; Hefflefinger, Maika; Tai, Tony; Baldzikowski, Monica; Au, Rebecca; Nguyen, Kendrix; Ratnesar, Dr. Rajendra; Mostovestsky, Olga; Custodio, Ralph; Absent:


1. Review: Action items

Collin/All 3:00-3:15 • Action Items from 12/15/2015

2. Standing Agenda: Overturned Appeals

Collin 3:15-3:30 • Discuss o UM o Rx

• Recommendations

3. Decision: P&P Review

Jim S. 3:30-3:45 • Utilization Management P&Ps will be presented at UMC • Approvals sent to QIC with UMC Minutes • P&P Summary

o UM-10 Dental Anesthesia o UM-19 Standing Referrals o UM-38 DME Criteria

4. Discussion: Denial Rates by Medical Director

Collin/Jim G 3:45-4:15 • Approval and Denial Data for CY 2015 Statistical Analysis requested to BI

5. Discussion: MSTR Denied Services by Medical Group

Collin 4:15-4:30 • Report Link • MSTR Essette UM Data from June 2014 till current • How will we use?

6. Proposal: 2 MD approvals for one-time benefit exception

Collin/Jim G 4:30-4:45 • 2 MDs required for one-time benefit exceptions • Potential to hold-up TAT • Reflected in UM-55 • Issue with only 1 MD on-call

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http://teams.sfhp.org/medman/UM%20Committee/Forms/AllItems.aspx?RootFolder=%2Fmedman%2FUM%20Committee%2F2016%2F1%2D%20January%202016%2FMeeting%20Materials&FolderCTID=0x0120005EC87A45938CB247A1E177C6968A0586&View=%7B2D9FE992%2D6FE0%2D4580%2D9FB2%2D31C58E74259F%7D

http://teams.sfhp.org/medman/UM%20Committee/2016/1-%20January%202016/Meeting%20Materials/Policy%20and%20Procedures/PP%20Summary%2001.27.16.docx

http://teams.sfhp.org/medman/UM%20Committee/2016/1-%20January%202016/Meeting%20Materials/Policy%20and%20Procedures/UM-10%20Dental%20Anesthesia.doc

http://teams.sfhp.org/medman/UM%20Committee/2016/1-%20January%202016/Meeting%20Materials/Policy%20and%20Procedures/UM-19%20Standing%20Referral%20to%20Specialty%20Care.docx

http://teams.sfhp.org/medman/UM%20Committee/2016/1-%20January%202016/Meeting%20Materials/Policy%20and%20Procedures/UM-38%20DME%20Criteria.docx

http://teams.sfhp.org/medman/UM%20Committee/2016/1-%20January%202016/Meeting%20Materials/MD%20Denial%20Rates%20CY%202015.docx

http://bi.sfhp.org/MicroStrategy/asp/Main.aspx?evt=4058&src=Main.aspx.4058&reportViewMode=1&_subscriptionID=173816354992AD336486FE934E2D143C&server=SRPBIIS01&Project=CKPIs&port=0&share=1

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7. Review: Next Steps/Action Item Review

Maika 4:50-4:55 Action Items IMR/State Hearing

ACTION ITEMS: ITEM



• 01.27.16 In progress per MB Figured out what codes would cover glucose monitoring strips. This is a SQ monitor. Will continue to check on this.

3. Jim G./Jim Soos • (1/27/15) For UMC decision on whether we will only require one physician to

approve one-time, non-covered MediCal services on a case-by-case basis, Jim G. will bring to ET and Jim S. to policy.

• (1/27/15) Jim G. and Collin will draft a report for claims to approve professional fees.

•

4. Collin • (1/27/15) Collin will update charter for voting structure and expand responsibilities. • (1/27/15) Collin and Jim will draft a report for claims to approve profession fees. • (1/27/15) Collin will follow up with Jose on denial data and how it’s captured. Can

we separate concurrent review from prior authorization? • (11/17/15) Collin to discuss with Jim the role the quality review nurse will take on


• • • • On hold Move to parking lot.

5. Rebecca • (1/27/15) Rebecca will reassess Metaformin use requirments for approval for second-line step therapy.

• (12/15/15) From the Cimzia appeal that was resolved on 11/19/15, Fiona and Rebecca will discuss Anti-TNF criteria– 6 months vs. 12 months approvals.

• • Initial – 6 months; Reauthorization is 24

months? Rebecca will follow-up.



• Fiona will follow-up with Dr. Raj. To be continued.

• Jim says that two denied by AASLD policy; one went to IMR based and overturned based on AASLD; one went to state fair hearing and was upheld.

7. • (1/27/15) Tony will do report on approved authorization edit 203. •

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1.

Continue PBM/Contracts action item to continue to dig up and figure out how much effort we would like to put into this. We are more concerned with the onesie and twosies. Lisa has been working with Russ in PNO to help fix this issue. We have looped back, but the work still needs to get completed. There are a number of LTC claims going through pharmacy and it has been found to be an inappropriate benefit. Laguna Honda is a little more complicated to set rates for non-CHN and CHN members.

12/15/15 Follow-up in Feb. 2016

2. Determine long-term solution for requesting visits for specialty care OOMG. • Create a long-term solution either by creating new processes. • Create a new process in UM or fold this into a new ANG process.

12/15/15 Continue follow-up for 2016


Feb. 2016 4. Collin to discuss with Jim the role the quality review nurse will take on for reviewing Pharmacy items. 1/27/15 On hold DECISIONS


1. If there is no notes indicating that the patient has consulted a psychiatrist, we can deny and provide Beacon services for non specialty mental health and evaluations. 1/27/15

2. We will add “stolen or lost language” to policy UM 38 for replacement wheel chair benefit. 1/27/15

3. We will create a report and discuss exception handling cases bi-annually to decide if we would like to make any of these non-covered MediCal services should be submitted for ongoing exception services. 1/27/15

4. We will craft a tentative professional fee policy change until the reconfiguration happens. 1/27/15 5. We will review overturned IMRs as they arise at UMC 1/27/15

Meeting Notes from Tuesday, 12/15/15: ACTION ITEMS: ITEM



• (11/17/15) Patty and Monica will add changes into the SFHP Criteria Transgender Services document from the THS discussion yesterday, and send a summary of the changes along with the edited document to UMC members to evote. Please include bullet points that have changed at the top.

• (10/26/15) Monica will follow-up to see if we have access to data for stratification by Type 1 as well as check HEDIS Data; talk to Raj whether or not he will approve

• 01.27.16 In progress per MB Figured out what codes would cover glucose monitoring strips. This is a sub-que monitor. Will continue to check on this.

• 01.27.16 Close. In final review per MD

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or deny these cases. (Any updates?) • 01.27.16 Close. Resolved to perform one

time exceptions. We will do exception handling.

3. Ralph • (12/15/15) Ralph to follow-up with Odalis to find out how the pharmacy audit went with Kaiser.

•

• 100% all elements.

4. Collin • (12/15/15) Collin will ask Jose for denial rates by medical directors. • (11/17/15) Collin to discuss with Jim the role the quality review nurse will take on


• 01.27.16 Complete • On hold Move to parking lot.

5. Rebecca • (12/15/15) From the Cimzia appeal that was resolved on 11/19/15, Fiona and Rebecca will discuss Anti-TNF criteria– 6 months vs. 12 months approvals.

• Initial – 6 months; Reauthorization is 24 months? Rebecca will follow-up.



• Fiona will follow-up with Dr. Raj. To be continued.

• Jim says that two denied by AASLD policy; one went to IMR based and overturned based on AASLD; one went to state fair hearing and was upheld.



Feb. 2016 2. Collin to discuss with Jim the role the quality review nurse will take on for reviewing Pharmacy items. 1/27/15 On hold DECISIONS


1. Decided to take on a short-term recommendation for increasing the number of units on specialty office visits OOMG (UM-19) 12/15/15

2. When we identify delegated issues, we will send to Ralph. 11/17/15 3. Compliance Clin Ops CMO File Review will be called Denial File Audits. 11/17/15

Overturned Appeals

UM No UM appeals for reporting period. Pharmacy

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• Harvoni – Additional information was submitted. Originally it met criteria but was denied because it lacked official documentation and was only stated in the

notes. Additional documentation was resubmitted. • Dextroamp- This didn’t have a psychiatrist evaluation and was denied. The appeal was given two months for Adderall 12mg and passed on to Beacon. SFHP

requested a psychiatry evaluation from the patient’s PCP or call Beacon Health. o If there is no evidence that the patient was referred to psychiatry then we can deny and offer the Beacon consulte service. Decision: If there is no notes

indicating that the patient has consulted a psychiatrist, we can deny and provide Beacon services. - clarify • Januvia – Originally denied because there was no mention of metaformin; overturned because patient was considered a medically complex diabetes patient.

o Action item: Rebecca will reassess Metaformin using requirments for approval for second-line step therapy. • Cimzia – Original request denied because there was insufficient clinical notes. After denial, the next day additional information was submitted. P&P Review Collin made an announcement stating that going forward, UM policies will be reviewed in UMC and then put in the consent calendar to be reviewed and passed at QIC. Pharmacy will do the same at P&T Committee for pharmacy policy changes.

o UM – 10 Dental Anesthesia: The state requires that we include specific language in our policy. All language is from APL on number 4. All Dental provdiers meet state requirements, which is number 5.

o UM – 19 Standing Referrals: This was an annual review. A couple of changes on page 1 of our procedures. Medical groups do not require medical authorization but OOMG/OON do.

o UM 38 – DME Criteria: The changes relate to APL 12018. The major change is on page 3 that requires a back-up replacement wheelchair when the current wheel chair is unavailable due to damage/needs repair. Wheel chairs reported as stolen may require a police report before replacement.

Decision: We will add stolen or lost language to policy UM 38 for replacement wheel chair benefit.

Policies voted on and unanimous approval with committee.

MD approvals for one-time benefit exception

Do we want to uphold the two-physician approval requirement for one-time exceptions? Jim is unable to make a medical necessity decision for an adult.

Exception-handling requests are occurring more frequently than not. Even though UM decided to approve non-covered codes/services, the configuration in the system does not support it. Claims has been calling UM frequently trying to figure out the issue regarding these exception-handling agreement. UM now owns the exception handling process.

Collin says we have unanimous agreement on re-opening UM-55 to discuss the two-physicial approval requirement.

For UMC decision on whether we will only require one physician to approve one-time, non-MediCal services on a case-by-case basis, Jim G. will bring to ET and Jim S. to policy.

Decision: We will create a report and discuss exception handling cases bi-annually to decide if we would like to make any of these non-Medical services actual covered benefits.

Denial Rates by Medical Director

Raj, Fiona, Scott, and Wayne (medical directors) denial an approvals were reviewed for concordance an IRR. .

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Raj has 814 approvals and of those 813 were approved based on medical necessity review. He denied or partially denied 990 cases, giving a 55% denial rate. 10 denials were upheld, and 28 wereopverturned, giving a 3% overturn rate. Donald has 506 approvals, 990 denials, providing a 55% denial rate. 2 denials were upheld on appeal and 12 were overturned, providing a 2% overturn rate. Wayne has 418 approvals, 589 denials, providing a 58% denial rate. 23 denials were upheld and 11 denials were overtuned by appeal, providing a 2% overturn rate. Are exception handling cases incorporated in what is considered as medical necessity review? Most likely yes and it would be difficult to tease out. This is good to review these numbers to make sure that our medical directors are approving and denying similarly, to make sure there is no differing interpretation of criteria. MSTR Denied Services by Medical Group We are looking at the UM Denied Service report pulled from Essette. This can only be used for CHN and UC, not delegated medical groups. Data breaks down QNXT service groups, what the category is, what the procedure code is, service description, total denied and approved. Is there anything we would like to look at across the board? Jim mentioned that Ralph has created a denial log which provides a specific reason. Can we look at inpatient care days? Committee continued to sift through CHN and UC services. We will continue to look at the relationship and differences between OOMG and OON, and we are shifting towards removing OOMG. This report is available to anyone who wants to look at this data. Professional Fees For No Auth or Denied Auth – is it okay to pay medically professional fees? This has been escalated to ET. Deena is going to talk to Dockins if there is a way at the claims level to address this. In the meantime, can Claims and the PDR team get something in writing that says until a final decision has been made for no auth or dened auth, we can pay the professional fee? Jim says this is an on-going conversation with Deena, but Matija says that UM has been affected by this since July 2015. Decision: We will craft this tentative policy change until the reconfiguration happens. Action Item: Collin and Jim will draft a report for claims to approve professional fees. IMR/State Hearing: Clinical overturned on externals

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Decision: We will review IMRs as they arise at UMC. Action Item: Collin will follow up with Jose on denial data and how it’s captured. Can we separate concurrent review from prior authorization? Action Item: Tony will do report on approved authorization edit 203. Action Item: Collin will update charter for voting structure and expand responsibilities.

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CARE-04: Complex Medical Case Management (CMCM) Major revision of existing place-holder policy. Please see P&P. Includes:

• Population assessment procedure • CMCM program description • Identifying SFHP members for CMCM

o CMCM member eligibility criteria o Review of candidates for CMCM o CMCM referral closure

• CMCM process o CMCM program intake o CMCM initial assessment o CMCM care planning o Follow-up o Criteria for CMCM continuation and case closure

• Role of the case manager o Coordination with colleagues o Case manager oversight o Documentation

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Complex Medical Case Management Policy and Procedure number:

CARE-04

Department Owner: Care Coordination Lines of Business Affected: Medi-Cal

POLICY STATEMENT San Francisco Health Plan (SFHP) Complex Medical Case Management (CMCM) provides case management to members identified as high risk due to complex medical conditions that require medical management and intervention. The CMCM program requires assessment of members’ qualifying medical conditions and contributing psychological factors, coordination with providers and community partners, and engagement of members in the development of their care plan. Members enrolled in CMCM receive intensive medical management, coaching and guidance for their medical conditions, and referrals to resources that allow them to regain optimum health and functionality. Care plans include significant support with health system navigation and coordination to facilitate appropriate delivery of care and services and condition-specific education and assistance with goal attainment, monitoring, and follow-up. CMCM member assessments used for initial and on-going case management are based on clinical best practices. SFHP CMCM is an opt-out program; all eligible members have the right to participate or to decline participation.

PROCEDURE

I. Population Assessment

The CMCM Program conducts an annual population assessment and analysis to ensure program relevance and uses the findings to adjust delivery methods and member service offerings accordingly. Populations assessed for CMCM services include:

a. Medi-Cal Seniors and Persons with Disabilities (SPDs) b. Members with multiple chronic conditions c. Members with high levels of utilization and/or recidivism d. Members of at-risk, ethnic, language, racial groups

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e. Children and adolescents, ages 2-19, including those with potential CCS eligible conditions

f. Individuals with disabilities The CMCM program reviews administrative data at least annually to assess the needs of the member population and sub-populations. Data are analyzed to ensure the program remains relevant to member needs. Analysis includes, but is not limited to:

a. Use of diagnosis codes to determine the distribution of chronic conditions, and identify membership with single and multiple chronic conditions.

b. Use of pharmacy data to identify trends in poly-pharmacy. c. Use of claims and authorization data to identify patterns of high utilization. d. Use of demographic data to identify at risk members by disability, age, ethnic,

language, racial groups. e. CMCM member satisfaction survey results – Members are given the

opportunity to provide feedback about the CMCM Program during the course of their CMCM engagement, prior to the closure of the case.

f. Use of the plan’s grievance data related to the member’s involvement in the CMCM Program, if applicable.

A formal annual evaluation of program resources, including carved-out benefits, staffing ratios, educational materials, and program communication, is conducted to provide a comprehensive overall assessment. The population analysis and evaluation of resources are used for program improvement. The final analysis is reviewed and approved by the Quality Improvement Committee (QIC). Any performance improvement activities are implemented in the subsequent year.

II. Program Description The CMCM program aligns with the standards of the Case Management Society of America (CMSA). As such, the CMCM program promotes a person-centric approach to achieve health goals. The program employs member self-care and behavioral change principles to assist a member to navigate and access health care benefits under the plan and access community resources for which they are eligible. The CMSA standards of practice are a component of the initial assessment and ongoing management in care plans utilized by the case managers. (See CMCM Program Description) Seniors and Persons with Disabilities (SPDs), adults and children at risk due to medical, psychosocial, and/or co-morbid problems are referred and evaluated for CMCM program appropriateness. An individualized care plan is developed with input from the member, member’s family/caregiver, and the member’s health care team to establish and monitor short- and long-term goals and identifies resources to assist in meeting the goals. The primary source for CMCM evidenced-based guidelines is the Institute for Clinical Systems Improvement (ICSI). If ICSI lacks a guideline, other sources are used (e.g.,

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medical society guidelines, AHRQ, NCBHI National Clearinghouse). The following clinical practice guidelines are used to support patient education for specific disease states:

Asthma www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_respiratory_guidelines/asthma/

Diabetes Mellitus in Adults, Type 2

www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_endocrine_guidelines/diabetes/

Heart Failure in Adults www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_cardiovascular_guidelines/heart_failure/

Obesity www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_endocrine_guidelines/obesity adults/

Case management is provided by licensed clinicians and experienced case managers including RNs, LVNs, LCSWs, master’s trained social workers and other health professionals, and bachelor’s trained case managers with strong ties to the community and services.

III. Identifying Members for Case Management Referrals sources for CMCM include:

a) Member or caregiver referral. b) Primary Care Provider and/or Specialist. c) Disease management (DM) program referral. d) Discharge planner referral (from all in-network and OON facilities). e) UM Nurse preforming preauthorization or concurrent review referral. f) Other internal plan staff referral (CareSupport, Compliance, Grievance

Committee) g) Other community-based providers/clinicians referral.

SFHP uses the following sources to identify members for CMCM:

a) Claims or encounter data. b) Hospital admission and discharge data. c) Pharmacy data. d) Data collected through the authorization process. e) Data provided by California Children's Services (CCS). f) Data supplied by the California Department of Health Care Services (DHCS),

including Health Information Forms (HIF) data.

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g) Data supplied by members or caregivers, including Health Risk Assessment (HRA).

h) Data from the plan’s Disease Management programs (Diabetes and Asthma), and health management programs, as of March 2016.

i) Predictive modeling data using Milliman Advanced Risk Adjusters (MARA), when available in 2016.

Members who are candidates for the CMCM program are referred to CMCM using the case management referral module in Essette.

A. CMCM Member Eligibility Criteria

Participation in the CMCM Program is voluntary. Members who are identified as high risk and meet the following criteria are eligible for CMCM:

a) A member of SFHP’s Medi-Cal lines of business. b) A member of one (1) of the following medical groups: Community Health

Network, University of California, San Francisco Medical Center (UCSF), Hill Physicians, Brown & Toland Physicians, North East Medical Services, or Chinese Community Health Care Association.

In addition, members must have one (1) or more of the following risks and would likely benefit from clinical intervention by case management staff:

a) Acute health care needs, post-emergency department (ED), or acute

hospitalization. b) Complex medical issues and/or multiple co-morbidities. c) Children with Special Health Care Needs (CSHCN). d) Poorly controlled disease states. e) High ED (more than four (4) ED visits) or inpatient utilization (more than two

(2) inpatient admissions) within a 6-month period.

AND members must have one (1) or more of the following needs: a) Challenges with adherence to treatment (medications, not showing for office

visits, etc.). b) Need assistance in coordinating care (e.g., facilitate communication between

providers, appointments, transportation, specialty visits). c) No Primary Care Provider (PCP) visit within six (6) months. d) Need for patient education about their significant chronic conditions. e) In need of assistance with identifying, referring, and accessing supportive

community care services.

B. CMCM Review of Program Candidates CMCM eligibility determination is made as soon as possible after receipt of clinical information and within fourteen (14) business days of referral. If additional clinical

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information is required to make an eligibility determination, then a determination of CMCM eligibility will be made within three (3) business days from receipt of the additional information. If additional information is not received within fourteen (14) business days of the request, a decision is made using the information available. CMCM eligibility determination will include consultation with the PCP when appropriate and/or treating provider and a review of some or all of the following system records:

a) System records of inpatient and outpatient claims, encounters, authorizations, and referrals for the past 12 months.

b) Appointment history for the past 12 months, including appointments attended and missed.

c) Coordinated Case Management Systems (CCMS), a database of city-wide case management enrollment.

C. CMCM Referral Closure Reasons for closure of a referral prior to enrollment include: a) Member has a previously established relationship with a community or provider-

based case management program and CMCM is a duplication of services. San Francisco Department of Public Health (DPH) maintains a database (CCMS) of patients currently under case management for use by DPH and non-DPH providers.

b) Member has not responded to three (3) or more program outreach attempts across a 2-week period, within the first 30 calendar days after eligibility. Weekly outreach is to be conducted both by telephone and by regular mail, and may include a home visit.

c) Member is transferred to a skilled nursing facility or other setting that provides case management.

d) Member is dis-enrolled from the health plan. e) Member is not willing or able to participate. f) Member is referred to or enrolls in a program that provides comparable case

management services. The review process must be thoroughly documented in Essette. If the member is not accepted into CMCM, then the decision is documented in Essette, with recommendations for appropriate follow-up to the referral source. Any prior established relationship with comparable case management program found during the review process will be confirmed and documented in Essette, and the referral will be closed with no further action. Cases referred to CMCM that are subsequently referred to and accepted by more appropriate case management services will be documented and then closed, with no further action taken.

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IV. Case Management Process

A. CMCM Program Intake Members who meet the CMCM program criteria are contacted by a case manager who explains the model and the nature of the case management. For members who verbally consent to participate, the case manager documents this consent in Essette. If consent is not received within thirty (30) days or if the member declines, the referral is closed. Program intake includes outreach to the primary care provider (PCP) and/or treating provider in order to discuss the referral and gather additional clinical information. If a member has no documented relationship with a PCP, then the care plan will include the goal of establishment of a patient/PCP relationship.

B. CMCM Initial Assessment

An initial visit in the home or comparable location is conducted within two (2) weeks from the member’s consent to participate. The case manager prepares for the initial home visit by conducting a record review using available clinical records, including:

a) System records of inpatient, outpatient, and pharmacy claims; encounters; authorizations (both approved and denied); and referrals for up to the last 12 months.

b) Appointment history for the past 12 months, including appointments attended and missed.

The case management assessment guides development of the individualized care plan and case management goals. The assessment process includes interviews with the member, family members, caregivers, the PCP and other providers and community-based services, as appropriate. The CMCM assessment is documented in the Essette Case Management module. Beginning at the time of the initial home visit and record review, the case manager gathers and documents the following: a) Current health status, including presence or absence of comorbidities and the

current status and the event or diagnosis that resulted in eligibility for the program.

b) Clinical history, including disease onset, acute phases, inpatient stays, treatment history and current or past medications, including schedule and dosages. The date of onset will be recorded as a calendar entry for the diagnosis listed in the medical record; any additional conditions will be recorded with the diagnosis and date of onset.

c) Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLS).

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d) Behavioral health status, including cognitive functioning, mental health conditions and substance abuse disorders.

e) Psychosocial status, including beliefs and concerns about the condition or treatment, perceived barriers to meeting treatment requirements, and access or transportation barriers.

f) Evaluation of visual and hearing needs to identify potential barriers to effective communication or care.

g) Cultural and linguistic needs to identify potential barriers to effective communications or acceptability of specific treatments. Includes consideration of cultural health beliefs and practices, preferred languages, health literacy and other communication needs.

h) Member perception of needs, goals, and preferences, including desired level of involvement in the case management program.

i) Self-management abilities and deficits. j) Assessment of barriers to meeting identified goals or complying with the

treatment plan (knowledge, skills, ability and motivation of member/caregiver; financial barriers, including food scarcity and housing)

k) Medication safety, whereby the case manager educates, assesses, and documents the member’s, and if applicable, the family’s or caregiver’s: Knowledge and understanding of current medications, including side

effects. Medication adherence. Maintenance of an up to date medication list. Medication storage

l) Need for medication reconciliation, if applicable. m) Safety concerns including risk factors for suicide, abuse, and violence. n) Initial assessment of life-planning activities, such as wills, living wills or advanced

directives. May exclude in pediatric cases. o) Evaluation of available benefits and resources necessary to meet health or

palliative care needs, including an evaluation of caregiver resources and needs. p) Evaluation of community resources, including the adequacy of plan benefits

relative to the treatment plan. q) Care coordination needs including transitions of care. The initial CMCM assessment is completed within 30 days of the member's verbal consent to participate in the CMCM program. Unavoidable delays in the completion of the initial assessment include member hospitalization or inability to contact member. In these instances the case manager documents the reasons for the delay and actions taken to complete the assessment. If the assessment reveals an urgent safety issue, such as abuse or suicide risk, the case manager must follow established plan protocols (see CARE-03 Client and Staff Safety).

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C. CMCM Care Planning Individualized care plans are developed in collaboration with the member and member's health care team. The case manager gathers all relevant medical, pharmacological, and treatment history information, collaborates with the member and treating provider(s) to identify short-term goals (achievable within 30 days), medium-term goals (achievable within 31-90 days), interventions to meet goals, barriers to goal attainment, resources to be utilized, time frames for re-evaluation (follow-up), and response to services. Goals priorities will be assigned as Low, Medium, or High. Initial care plans are completed within ten (10) business days of completion of assessment, and are modified and updated based on progress toward goals. All care plans are entered in Essette's Case Management module. Documentation in Essette to include:

a) Development of an individualized case management (and self-management) care plan, including prioritized goals that reflect the member’s and caregivers’ goals, preferences, and desired level of involvement.

b) Identification of barriers to a member meeting goals or complying with the plan.

c) Planning for continuity of care. d) Resources to be utilized, including benefits and services available through

community and governmental resources. e) Development of a schedule for follow-up and communication with members. f) Time frame for reevaluation to assess members’ progress toward goals. g) Member confirmation of the care plan (communicated verbally, either in-

person, or by phone.)

If a member, and/or caregiver, is unable or unavailable to participate in the development of the case management plan, the case manager contacts the provider to determine if there is a healthcare proxy or guardian to be involved with the decision-making for safety and welfare issues. In cases of some urgency, case managers rely on the clinic, specialty or in-patient attending physician to make decisions regarding the member’s treatment. D. Case Management Follow-up Case management follow-up interventions support progress toward care plan goals, and may include:

a) Development and communication of member self-management plans b) Counseling c) Member education d) Follow-up after referral to a resource or other program

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Members will be monitored and reassessed to determine the need to adjust the care plan and goals based on:

a) The response to the follow-up interventions. b) Progress toward goals. c) Evaluation of the barriers to the goals.

Follow-up on all referrals will be scheduled at time of the referral and can be combined as part of the next scheduled contact, if not considered urgent. Follow-up on progress toward a specific goal is no longer required once that goal has been achieved. Reassessments may move a member between risk levels at which time interventions are modified accordingly. The “Member/Provider Follow-up and Communication Plan” below is provided as a guideline for contact periodicity. Member/Provider Follow-up and Communication Plan

Member Status Communication High-Risk High-risk members may require prompt attention to address crisis and/or to ensure health and safety. These members present with a combination of the following factors: • Recent or ongoing ED/IP utilization within the last month • Multiple unmanaged chronic conditions • Any specialty mental health and/or substance abuse

diagnosis • Low self-efficacy (poor appointment compliance, limited

mobility, very limited participation in own care) • Low Health Literacy(?) • Lack of social support/isolation • Challenges meeting basic needs, such as housing, food,

in-home support and transportation • Moderate to severe cognitive impairment

The minimum recommended contact is four (4) in-person, phone or email contacts per month.

Medium Medium-risk members have chronic and ongoing needs—both medical and social. Member is motivated to change and has capacity to manage needs with moderate direction and assistance. Member is receptive to and welcomes health education coaching in regards to self-efficacy and self-advocacy. Member can maintain regular PCP appointments and requires moderate assistance with specialty/new providers. Most basic needs are met.

The minimum recommended contact is two (2) in-person, phone or email contacts per month.

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Member Status Communication Low (Maintenance) Member is high functioning (utilizes medical system appropriately and has a system in place to manage medication), adequate social and medical support, informed of many community services, connected to appropriate services, and most basic needs are met. Client has fewer and more concrete goals and is moving toward “well managed” and maintenance.

The minimum recommended contact is one (1) in-person, phone or email contacts per month.

E. CMCM Continuation/Closure Criteria Criteria for Program Continuation Ongoing CMCM program participation is based on an assessment of progress toward goals, including: a) Continued need for coordination with primary care or treating providers to

address unmet medical needs. b) Continued need for care and service coordination to prevent negative health

outcome(s). c) Continued need for patient/family education to prevent deterioration in health

status. Criteria for Case Closure The case manager submits cases to the Program Manager for closure that meet one (1) or more of the closure criteria below. The case manager will document and route cases for closure using Essette. Closure criteria include:

a) Member completed case management goals. b) Member is no longer in need of service. c) Member is lost to care or does not engage in service. d) Member declines case management or chooses to terminate service. e) Member no longer eligible based on eligibility criteria in section III. A., above. f) Member is referred to or enrolls in a program that provides comparable case

management services. g) Member is transferred to another setting and no longer requires case

management. h) Member refuses necessary psychosocial services and/or medical services. i) Member death. j) Member is not compliant with plan of care. k) Member has attained maximum improvement. l) Interventions are not successful/all resources exhausted.

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m) Member demonstrates inability to benefit from the program as evidenced by nonparticipation with CMCM treatment goals and care plan for a period of 60 days.

V. Role of the Case Manager

The case manager collaborates with members, families and or/caregivers, PCPs, specialty providers and community-based agencies, to ensure the provision of timely and appropriate healthcare services for both acute and chronic conditions. The case manager utilizes a person-centered approach to develop and implement individualized care plans to optimize the member’s health status, function, and enhance self-management knowledge and skills. The case manager conducts a thorough member assessment to ensure that the care plan is person-centered and addresses the member’s health care needs, priorities, goals, abilities and preferences, including desired level of participation. The case manager will coordinate services, including carved-out and linked services, to ensure the timely delivery of services, and will reduce, eliminate, or address any barriers adversely affecting progress toward goals. The case manager makes referrals to appropriate community resources and other agencies. The case manager monitors and documents progress toward goals, and updates care plans annually, if not sooner, to ensure interventions are responsive to the member’s health care needs. When necessary, the case manager accompanies the member to provider office appointments to review and discuss the care plan. The case manager communicates and coordinates across multiple disciplines and settings, including specialists, acute and sub-acute providers/case managers, home health, wound care, pharmacy, behavioral health providers, community agencies, homeless shelters and clinics. The case manager presents cases for review at monthly multi-disciplinary team meetings. The team identifies opportunities for improved medical and/or logistical management for members with complex needs. Cases reviewed include those without appreciable progress toward goals, and those requiring care coordination across SFHP UM, Pharmacy, and other departments. The team includes an SFHP Medical Director, and representation from SFHP UM, Pharmacy, CareSupport (social worker) and behavioral health staff. The case manager documents all multi-disciplinary communication and coordination in Essette. The case manager ensures the member and member designees have the opportunity to participate fully in any discussion or decisions regarding treatments and services. The case manager shall ensure the member receives all necessary information regarding treatment and services so that they may make an informed choice. The case manager provides member and family education, as indicated.

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The case manager will carry and display a SFHP-issued picture ID during off-site patient conferences or field-based case management activities. Case managers are encouraged to check in and out with the CMCM Program Manager before and after these activities. A. Coordination with Colleagues The case manager is responsible for coordinating and integrating case management services with appropriate case management colleagues, including, but not limited to:

• Plan and/or county-based behavioral health case managers • Substance abuse treatment providers • Homeless shelter case managers • Case managers associated with local area programs, such as the Golden

Gate Regional Center (GGRC) and California Children’s Services (CCS), To ensure that members receive fully integrated care, the case manager consults with the identified appropriate case manager colleagues on all cases with co-morbid conditions, once the member’s written permission to disclosure protected health information (PHI) is received. The case manager initiates contact with the colleague whenever a member is identified as needing assessment and/or additional supports requiring additional expertise. The case manager informs the case manager colleague whether the referral appears routine or urgent in nature. When the case manager colleague confirms that a referral has been accepted, the CMCM case manager shares demographics and relevant clinical information and clarifies the nature of the collaborative request. Any member information is shared as required or permitted by applicable regulatory, federal, or state confidentiality laws. The CMCM case manager and colleague will delineate their respective responsibilities and timeframes associated with tasks. CMCM care plans, goals, responsibilities and timeframes are documented in Essette. Documentation includes the dates and times of contacts between the clinical staffs and details related to the planned next steps. CMCM case manager and colleague will remain involved in co-managed cases until mutual determination by the member and/or health care team that co-management is no longer required. B. Case Manager Oversight The case manager is supervised by the CMCM Program Manager, under the guidance of an SFHP Medical Director. The case manager(s) meets weekly with the CMCM Program Manager to review cases. Case review also includes a review of short- and long-term goals and an evaluation of progress toward goals.

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Prior to planned time-off, the case manager is responsible for providing a report of current cases to the CMCM Program Manager or designated colleague. The case manager alerts the CMCM Program Manager with any concerns regarding the ability to safely and effectively manage a single case or overall case load. Together with the Program Manager and/or SFHP Medical Director, the case manager reviews the case or cases in question to determine next steps. Case review may include determination of whether a case or cases still meets criteria for participation in CMCM. The case manager submits for review cases ready for closure to the CMCM Program Manager. Following approval of a case closure, the case manager notifies all relevant parties. The case manager is responsible for thorough case documentation, and case review findings will be used to assess the case manager’s performance. The case manager is required to participate in additional training or other remediation activities if a deficiency or deficiencies are found. Case managers will consult with the SFHP Medical Director on an as needed basis during the assessment and case management process, in order to obtain guidance regarding:

a) Members with co-morbid behavioral health and medical issues. b) Comprehensive diagnostic workups. c) Members with medication or polypharmacy issues. d) Treatment of averse members, including those opposed to seeking needed

health care. e) Complex situations and/or crisis planning. f) Identification of potential quality issues and follow-up next steps.

C. Documentation The case manager documents case management activities in Essette, which provides data integration and clinical consulting tools for member case management. This system supports:

a) Evidence-based clinical guidelines or algorithms to conduct assessment and management.

b) Automatic documentation of the staff member’s ID and date, and time of action on the case or when interaction with the member occurred.

c) Automated prompts for follow-up, as required by the case management plan. d) Contact logs, including contact information and role of support persons and

collaborating community providers. e) Assessments.

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f) Date/Time stamped case progress notes, including details of referrals, need for coordination with other service providers and actual coordination of services that takes place.

g) Releases signed by participants to facilitate communication with support persons and collaborating providers.

MONITORING

SFHP annually measures the effectiveness of its CMCM program using three (3) measures. For each measure, SFHP:

a) Identifies a relevant process or outcome. b) Uses valid methods that provide quantitative results. c) Sets a performance goal. d) Clearly identifies measure specifications. e) Collects data and analyzes results. f) Identifies any opportunities for improvement.

The results of the measurement and analysis, along with opportunities for quality improvement are reported annually to the plan’s Quality Improvement Committee. Based on the results of its measurement and analysis of CMCM effectiveness and satisfaction, SFHP:

a) Implements at least one (1) intervention to improve clinical performance. b) Implements at least one (1) intervention to improve member satisfaction. c) Remeasures to determine impact on clinical performance, if applicable. d) Remeasures to determine impact on member experience, if applicable.

DEFINITIONS Activities of Daily Living (ADLs) – Routine activities that people tend to do every day without needing assistance, including eating, bathing, dressing, toileting, transferring, and continence. An individual’s ability to perform ADLs independently is important for determining what type of long-term care an individual needs. Complex Medical Case Management (CMCM) – Assessment of members qualifying medical condition(s) and contributing psychological factors; intense coordination with providers and community partners; and engagement of members (family/caregivers) in the planning and implementation of their care plan. Members enrolled in CMCM receive coaching and guidance for their medical conditions and referrals to resources that will allow them to regain or maintain optimum health and/or functionality. Care plans reflect care coordination, condition-specific education, advocacy, and system navigation to meet the member’s (family’s) comprehensive health needs, based on available resources. CMCM Program assessments are based on clinical best practices. Person-Centered Planning – as defined by the California Department of Health Care Services, is a highly individualized and ongoing process to develop individualized care plans that focus on a person’s abilities and preferences.

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Children with Special Health Care Needs (CSHCN) - as defined by the Federal Maternal-Child Health Bureau, are children who have or are at increased risk for chronic physical, behavioral, developmental, or emotional conditions and who also require health or related services of a type or amount beyond that required by children generally.

AFFECTED DEPARTMENTS/PARTIES Utilization Management Disease Management CareSupport/Customer Service

RELATED POLICIES AND PROCEDURES AND OTHER RELATED DOCUMENTS CARE-01 Care Coordination CARE-02 Risk Stratification, Health Information Forms (HIFs), and Health Risk Assessments (HRAs) CARE-03 Client and Staff Safety QI-13 Disease Management UM-20 California Children’s Services UM-33 EPSDT Complex Medical Case Management Program Description Disease Management Program Description

REVISION HISTORY Effective Date: February 12, 2015 Approval Date: February 12, 2015 Revision Date(s): January 15, 2016

REFERENCES DHCS/SFHP Contract, Exhibit A, Attachment 11, Provision 1; Exhibit A, Attachment 18, Provision 11 NCQA Standard QI 7 Complex Case Management

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P.O. Box 194247 San Francisco, CA 94119 1(415) 547-7800 1(415) 547-7821 FAX www.sfhp.org

6279X 0515

Date: February 8, 2016 To Quality Improvement Committee

From Nicole A. Ylagan – Grievance Analyst Kirk McDonald – Program Manager, Utilization Management

Regarding Q3 2015 Grievance & Appeals Report

A total of 159 grievances were reported in the third quarter of 2015 (from July 1 - September 30). In comparison to the second quarter of 2015 (147 grievances), this is an 8.1% increase. There were five grievances out of 159 grievances in which the acknowledgement letter was not sent out within five calendar days. The acknowledgement letters were overlooked and sent out late. There were 19 out of 159 grievances in the third quarter that were not closed in required 30 day timeframe, as mandated by the Department of Managed Health Care (DMHC) and Department of Health Care Services (DHCS). These grievances were not acknowledged and closed within their timeframes because of a new SFHP internal process that ensures all components of the grievance have been resolved appropriately and have been discussed by the weekly Grievance Review Committee (GRC).

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Grievances filed by members who are Seniors and Persons with Disabilities (SPD): In Q3 2015, 66 grievances were filed by members who are part of SPD population. This quarter, the number of grievances filed by members who are part of the SPD population decreased by 2.9% compared to the prior quarter. The most grievances received in the past three quarters were due to issues related to denials and quality of service.

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The most grievances received by members who are not SPDs in the past three quarters were due to issues related to denials, qualify of service and quality of care.

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Grievances by Category (All Lines of Business): During the past three quarters the top three categories identified were related to denials, quality of service and quality of care.

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Grievances by Medical Group:

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Beacon Grievances: From Q1 – Q3 2015, there were a total of six grievances associated with Beacon. Two of the six grievances were filed because Beacon’s Member Service Center did not have the correct phone numbers to providers. Beacon also reports that it has been challenging to increase the number of providers in their network.

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Access Grievances: In Q3 2015, there were 24 grievances related to members’ issues accessing care, compared to nine grievances in Q2 2015. There were six grievances related to a long time to schedule an appointment; three of which requested appointments with primary care providers and three requested specialty appointments Of the six access-related grievances related to a long time to schedule an appointment: • Two members were offered an appointment time within the Department of Managed

Health Care’s (DMHC) Timely Access Regulations (TAR). The TAR mandates that health plans provide PCP appointments within 10 business days of the member’s request and specialty appointments within15 business days.

• One member was not provided an appointment that met DMHC Timely Access Regulations due to a long wait list for a sleep study.

• One member was not provided an appointment that met DMHC TAR but the member’s provider indicated that an earlier appointment was not necessary.

• Two members were able to see other providers in the clinic rather than their assigned PCP.

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P.O. Box 194247 San Francisco, CA 94119 1(415) 547-7800 1(415) 547-7821 FAX www.sfhp.org

Date: February 8, 2016 To SFHP Quality Improvement Committee

From Abby Wolf, RN, PHN, Nurse Specialist, Provider Quality and Outreach

Regarding 2015 Facility Site Review Results

Background: The California Department of Health Care Services (DHCS) requires Medi-Cal Managed Care Plans to conduct a Full Scope Facility Site Review (FSR) for every Primary Care Provider (PCP) site as part of the initial credentialing process and at least every 36 months thereafter. The Full Scope FSR consists of two scored components that help ensure consistent compliance with DHCS administrative and clinical guidelines:

1. Site Review Survey (SRS) 2. Medical Record Review (MRR)

Both FSR components are scored by Certified Nurse Reviewers (CNRs) using standardized audit tools developed by DHCS. Scoring guidelines are as follows:

Site Review Survey 90-100%* - Exempted Pass

80-89% - Conditional Pass with Corrective Action Plan (CAP) Less than 80% - Non-pass

*Regardless of overall score, CAP is required for any deficiencies in Infection Control, Pharmaceutical Services, or Critical Elements

Medical Record Review 90-100%* - Exempted Pass

80-89% - Conditional Pass with CAP Less than 80% - Non-pass

*Regardless of overall score, CAP is required if any individual section score is below 80%

FSRs are conducted by SFHP and Anthem Blue Cross in the City and County of San Francisco. Per DHCS guidelines, FSR results are shared between the two Health Plans to avoid over-auditing PCP sites. The following SFHP Medical Groups are delegated to perform FSRs: Brown and Toland (BTP), Chinese Community Health Care Association (CCHCA), Hill Physicians (HPMG), Kaiser, and North East Medical Services (NEMS).

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The following tables summarize all FSR scores from Calendar Year 2015. Many PCPs participate in more than one medical group; however, providers are only listed once, by medical group that performed the FSR. It is also important to note that the SRS and MRR are sometimes conducted separately. For instance, an initial SRS is conducted for new sites as part of the initial credentialing process, but the MRR will be delayed by approximately six months to allow providers time to see new Managed Medi-Cal patients. Therefore, the number of SRS reviews may differ from the number of MRR reviews for a specified time period.

2015 Site Review Scores Summary

Medical Group

Number of Exempted

Pass Scores

Number of Conditional Pass Scores

Number of Non-Pass

Scores

Number of CAPs issued

Average Score

BTP 3 2 0 3 93% CCHCA 23 2 0 11 96%

CHN 9 0 0 5 97% HPMG 7 1 0 5 95% NEMS 9 0 1* 3 95% UCSF 6 0 0 2 97%

*Provider participates with NEMS, HPMG, and BTP and is no longer part of the SFHP network

2015 Medical Record Review Scores Summary

Medical Group

Number of Exempted

Pass Scores

Number of Conditional Pass Scores

Number of Non-Pass

Scores

Number of CAPs issued

Average Score

BTP 3 4 0 4 89% CCHCA 22 3 0 8 85%

CHN 7 3 0 3 92% HPMG 3 4 1 5 85% NEMS 4 0 2* 1 85% UCSF 2 1 0 1 93%

*Both non-passing scores are for provider participating with NEMS, HPMG, and BTP; first score was part of periodic MRR, second score was for follow-up MRR; provider is no longer part of the SFHP network Additional Information: Starting in 2016, FSR scores will be tracked closely and compared with previous scores for each PCP site. An FSR measure has been added to the 2016 Quality Improvement Plan with a target of SRS and MRR score increases of 2 percentage points from 2013 reviews when possible (N/A for scores of 99-100%). Activities that will help reach this target include more comprehensive CAP follow-up, increased provider outreach and training, and regular training of Certified Nurse Reviewers.

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Health Education and Cultural and Linguistic Services (HECLS) 2015 Medical Groups Audit – Summary of Findings January 28, 2016

C O N F I D E N T I A L Page 1 of 2

MEDICAL GROUP HEALTH EDUCATION CULTURAL AND LINGUISTIC SERVICES SAN FRANCISCO HEALTH NETWORK A Corrective Action Plans (CAP) was submitted by the group and approved by SFHP.

Score: 63% 1. HEALTH EDUCATION STANDARDS

Documentation provided do not indicate whether health education materials are available at the providers’ office; whether health education materials are available at no cost to members; and whether health education materials are available in Chinese, Spanish, and Vietnamese.

Score: 83% 2. PROVISION OF INTERPRETER SERVICES

All requirements were met. 3. CONFIDENTIALITY OF INTERPRETER

SERVICES All requirements were met.

4. MEDICAL GROUP STAFF AND PRACTITIONERS TRAINING Policy describing the procedure for coordinating/holding ongoing cultural competency trainings for the medical group’s practitioners and staff that come in contact with members was not provided. Training curriculum did not include evidence that members receive information about how to work with SPD members.

UCSF A Corrective Action Plans (CAP) was submitted by the group and approved by SFHP.

Score: 38% 1. HEALTH EDUCATION STANDARDS

SFHP could not verify that Health Ed classes are provided at no cost to the member; Health Ed classes are provided in Chinese, Spanish, and Vietnamese; and that Health

Score: 83% 1. PROVISION OF INTERPRETER SERVICES

All requirements were met. 2. CONFIDENTIALITY OF INTERPRETER

SERVICES

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Health Education and Cultural and Linguistic Services (HECLS) 2015 Medical Groups Audit – Summary of Findings January 28, 2016


MEDICAL GROUP HEALTH EDUCATION CULTURAL AND LINGUISTIC SERVICES Ed materials are written at the sixth grade reading level. Documentation regarding the method for delivering health education classes was not provided.

All requirements were met.

3. MEDICAL GROUP STAFF AND

PRACTITIONERS TRAINING Policies and procedures describing the process for conducting staff training, and evidence that staff had received training were not provided at the time of the audit.

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Quality Improvement (QI) 2015 Medical Groups Audit – Summary of Findings November 30, 2015


BROWN AND TOLAND – Audit Score 69%

QI Program and Evaluation Access: Office Wait Time and F/U on Missed Appointments

IHA and IHEBA

• QI Program does not include objectives for

serving a culturally and linguistically diverse membership.

• QI Program does not clearly describe objectives for serving members with complex health needs.

• The group did not provide evidence that it conducted an evaluation of the QI Program in 2014.

• No evidence that QI Program is shared with providers.

All requirements were met. • Results from the 2014 CG-CAHPS survey

indicate that 50.2% of survey respondents agreed that they waited 15 min or less in the waiting room.

• SFHP reviewed 70 patient charts and found that 26 patients had missed appointments. The practitioners’ office had documented follow up on 100% the cases.

• Initial Healthy Assessment (IHA): SFHP

reviewed 70 patient charts and found 97% to be compliant with this requirement.

• SFHP reviewed 70 patient charts of members that should have received an initial IHEBA or follow up IHEBA and found that 41% patients had received the service.

Corrective Action Plan Plan for corrective action was submitted, evidence that the plan was implemented is pending. SFHP will follow up with Brown and Toland QI Director to ensure that corrective action is completed prior to 2016 onsite audit.

No corrective action required Plan for corrective action was submitted, evidence that the plan was implemented is pending. SFHP will follow up with Brown and Toland Physician Services Department to deploy training to PCPs.

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CCHCA – Audit Score 88%


IHA and IHEBA

• Assessment of the Program is mentioned;

however, no there is no mention that the group evaluates trends.

• QI Program does not describe how practitioners can participate in the planning, design and implementation of the QI Program.

• Results from the 2014 CG-CAHPS survey

indicate that 15.7% (required 20%) of survey respondents agreed that they waited 15 min or less in the waiting room.

• SFHP reviewed 67 patient charts and found that 46 patients had missed appointments. The practitioners’ office had documented follow up on 92% the cases. Please refer to Basic CM audit for details.



• SFHP reviewed 67 patient charts of members that should have received an initial IHEBA or follow up IHEBA and found that 76% patients had received the service

Corrective Action Plan Plan for corrective action was not submitted. SFHP will follow up with CCHCA Director of Operations to ensure that corrective action is completed prior to 2016 onsite audit.

The group implemented a plan for corrective action that includes sending periodic reminders to its physicians regarding access standards.

No corrective action required

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HILL PHYSICIANS – Audit Score 57%


IHA and IHEBA

• Outcomes measurement is mentioned in the

QI Program; however, no evidence was provided during the audit.

• SFHP could not verify that the group annually makes information about its QI program available to practitioners.



• SFHP reviewed 49 patient charts and found that 20 patients had missed appointments. The practitioners’ office documented follow up on 35% the cases.



• SFHP reviewed 50 patient charts of members that should have received an initial IHEBA or follow up IHEBA and found that 39% patients had received the service

Corrective Action Plan SFHP is in the process of reviewing medical group CAP.

SFHP is in the process of reviewing medical group CAP.


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NEMS – Audit Score 76%


IHA and IHEBA

• No evidence that the group assess

performance in the quality and safety of clinical care and quality of service.

• No evidence that QI Program is shared with providers.



• SFHP reviewed 70 patient charts and found that 47 patients had missed appointments. The practitioners’ office documented follow up on 89% the cases. Please refer to Basic CM audit for details.

• SFHP reviewed 70 patient charts 100% to be

compliant with this requirement. • SFHP reviewed 70 patient charts of

members that should have received an initial IHEBA or follow up IHEBA and found that 92% patients had received the service.

Corrective Action Plan SFHP is in the process of reviewing medical group CAP.


No corrective action required

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Telehealth for SFHP Jim Glauber, MD, MPH Chief Medical Officer

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Why SFHP Needs to Improve Access to Care

• 55% of SFHP members did have not PCP visit in 2015

• Lowest CAHPS scores of any Medi-Cal Plan in 2013

• Adverse Regulatory Scrutiny (DHCS and DMHC)

• CMS-required access study of CA Medicaid Managed Care Plans as condition of waiver approval

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What Is Telemedicine?

• Use of medical information electronically exchanged between sites to improve a patient’s health status

• Employs two-way video, email, smart phones, and wireless tools

• Includes direct patient services from primary, specialty, BH providers, remote patient monitoring tools, diagnostic image sharing delivered by telemedicine

• No separate coding or reimbursement for services provided on site versus those provided through telemedicine 3 120

Telemedicine Is a Component of SFHP Overall Access Improvement Strategy

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• PIP Program Funding that Rewards Measured Improved Primary Care Third Next Available (TNAA) and Member Satisfaction with Access

• Technical Assistance and Coaching on Access Improvement Strategies

• Heightened Monitoring Through Access Dashboard

• Beacon is contracting with Teladoc to add BH clinicians to existing network

• $5M proposed FY15/16 PIP Block Grant Funding to Increase Primary Care Capacity, including telehealth

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What Problems Do Telemedicine Help Address?

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• Primary care appointment availability varies widely throughout network; many practices do not meet DHCS Timely Access Standards

• Only 7 of 21 FQHC primary care clinics have Third Next Available Appointment <14 days

• SFHP CAHPS scores lowest among Medi-Cal Plans; 66% “always or usually” for Getting Care Quickly composite; 15% below NCQA 90%

• 35% of primary care practices do not meet after-hours telephone availability requirements; Corrective Action Plans required for these practices

• SFHP cited for several access & availability deficiencies in 2015 DHCS and DMHC Medical Audits

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Why Telemedicine? Top10 SFHP ER

Diagnoses

6

Top10 Teladoc Diagnoses

Condition Chest Pain Unspecified

Fever Unspecified

Acute Uris of Unspecified Site

Abdominal Pain

Headache

Pain in Soft Tissues

Altered Mental Health Status

Cough

NONDPND Alcohol Abuse UNS Drunkenness

Shortness of Breath

Condition Acute Respiratory

Urinary Tract Infections and Urinary Symptoms

Skin Problems

Abdominal Pain, Vomiting, and Diarrhea

Back and Joint Problems

Influenza and General Viral Diseases

General Advice Counseling and Refills

Eye Problems

Ear Infections

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Why Telemedicine? Time Spent Seeking Medical Care

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146 150

123

100

110

120

130

140

150

160

Non-Hispanic,white

Non-hispanic,black

Hispanic Other

Adjusted Total Time, includes Clinic and Travel Time (minutes)

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Kristin N. Ray, MD, MS., et al. Disparities in Time Spent Seeking Medical Care in the United States. JAMA Internal Medicine. 2015: 4468(E1)

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Telemedicine: Next Steps

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• RFP issued 10/3; Vendor selection target date 12/18; Governing Board proposal 3/16; Implementation, if approved, Q3 2016.

• SFHP proposes paying for primary care and NSMH telemedicine visits FFS; no cap adjustment.

• Anticipated year 1 use: 10-15%

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AGENDA - San Francisco Health Plan · • A new QIC Committee member was announced - Dr. Ana...

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