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Peach State Health Plan Cultural Competency Program

2017 Annual Evaluation

The Cultural Competency Plan (CCP) Annual Evaluation is an assessment of data and the effectiveness of interventions in the prior year. Continuous activities and initiatives that are designed to meet goals of the Strategic CCP are acknowledged. This document addresses only data, activities and interventions encountered in the prior year that presented opportunities for improvement and awareness.

Peach State Health Plan’s Cultural Competency Committee is comprised of cross-functional leaders from various disciplines, including Provider Operations/Relations, Member Services, Compliance, Quality Improvement, Human Resources, Marketing & Communications, and Case and Utilization Management.

The committee monitors and reviews the CCP Work Plan throughout the year to track progress to ensure that Peach State Health Plan staff and Network Providers are on target for delivery of culturally and linguistically appropriate care and service to all of Peach State Health Plan’s members and communities.

Experiences and observations of committee members who regularly interface with the provider, member, communities, and staff allow for feedback and identification of any barriers/issues and opportunity to continually improve cultural and linguistic competency. Peach State Health Plan responds to customer and staff concerns, suggestions, and recommendations as presented.

Network providers may access the full strategic plan at www.pshpgeorgia.com,

http://www.pshpgeorgia.com/for-providers/cultural-competency/, and request a hard copy at no charge.

Key Activities in areas of interpretation, partnerships, as well as, community events were maintained in 2017 with continue strengthening and improvement of member outcomes and engagements:

• Notification to all members and providers of the availability of interpretation services and how to access bilingual interpreter service

• Provision of free language interpretation services and cultural awareness information to providers• Offer of free linguistic services to members as needed with assistance at points of member contact

with interpretation services via telephone, face-to-face, and during doctor’s office visit• Distribution of all member communications including educational materials in English and Spanish•

Envolve PeopleCare (Disease and Case Management Vendor) and Envolve Benefits (Dental and Vision Vendor) supported Peach State Health Plan Community Events in 2017 by attending and presenting at various community events. Vendor offer services in both English and Spanish. Printed educational materials were also offered in both English and Spanish.

• Audit of all Vendor CCP and language assistance capability

Peach State Health Plan’s Cultural Competency Committee focused on observations across three products and monitored 2017 selected interventions by functional areas. All of the following top areas for members at risk (barriers) for disparity continues to be addressed:

• Afro Americans at higher risk for conditions (HIV, DM, HTN etc.) •

Not enough focus on high risk conditions• Physician lack of awareness regarding Health Disparities• Differences in provision of health care between Black and White Race

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Quantitative AnalysisSelected High Risk Conditions - 2017 ObservationsMedicaid Outreach Impact – 2017

Medicaid Envolve PeopleCare (DM Vendor) reports a total of 1818 Medicaid members with episodes of care for Diabetes engaged in health coaching during 2017. 100% of those members were reported with a confirmed diagnosis of Diabetes. At the end of December 2017, 56 (%) of those members remained active in health coaching 1024.

AmbetterEnvolve PeopleCare (DM Vendor) reports a total of 4609 Ambetter members with episodes of care for Diabetes engaged in health coaching during 2017 (4609 members identified with confirmed diagnosis). At the end of December 2017, 50 % of those members remained active in health coaching 2336.

Medicare Envolve People care (DM Vendor) reports a total of 98 members with episodes of care for Diabetes engaged in health coaching during 2017(100% identified with confirmed diagnosis). At year end, December 2017, 55 of those members remained active in health coaching.

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Membership Data at Year End 2017Peach State Health Plan Rank Order of Population by RaceCurrent Gender/Age Status – December 2017

MEMBER COUNT - Medicaid

GA - Age Cohort Female Male Total

0-9 87,875 90,668 17854310-19 64,072 61,845 125917

20-34 40,242 2,060 4230235-50 15,840 2,494 18334

>50 1,872 498 2370 209,901 157,565 367,466

MEMBER COUNT - Ambetter GA - Age Cohort Female Male Total0-9 90 76 16610-19 220 203 42320-34 11,359 10,192 21,55135-49

19,384 19,869 39,253>49 25,243 27,882 53,125 56,297 58,222 114,519

MEMBER COUNT - Medicare GA - Age Cohort Female Male Total20-34 8 1 935-50

25 10 35

>50 273 152 425 306 163 469

Medicaid total membership @ December 2017=

Data provided by Finance

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Population By Race

Medicaid

Race Description Member Count % of Population

Black or African American 300,739

54.33%Caucasian - European Americans 200,362 36.19%

Other 19,638 3.55%NA 14,914 2.69%

Asian 14,834 2.68%American Indian and Alaska Native 915 0.17%Black Non-Hispanic 761 0.14%

White Non-Hispanic 605 0.11%Native Hawaiian and Other Pacific Islander 527 0.10%

Hispanic 278 0.05%

Grand Total 553,573 100.00%

Ambetter

Race Description Member Count % of Population

White 45,749 26.27%Unknown Race 41,245 23.68%Black or African American 40,538 23.28%

Asian 33,356 19.15%Some other race 12,841 7.37%American Indian and Alaska Native 260 0.15%Native Hawaiian and Other Pacific Islander 154 0.09%

Grand Total 174,143 100.00%

Medicare

Race Description Member Count % of Population

N/A 650 100.00%

Grand Total 650 100.00%*All Medicare members are in the Population reported as Unknown Race and Unknown Ethnicity

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Current Gender by Age Status

MedicaidGender Age 0-9 Years Age 10-19 Years Age 19-34 Years Age 35-50 Years Age 50+ Years Grand Total Female 124,296 99,066 67,077 26,922 2,781 320,142

Male 127,919 96,404 3,831 4,336 941 233,431 Grand Total

252,215 195,470 70,908 31,258 3,722 553,573

AmbetterGender Age 0-9 Years Age 10-19 Years Age 19-34 Years Age 35-50 Years Age 50+ Years Grand Total

Female 2,813 4,665 27,174 29,401 32,711 96,764Male 2,874 4,887 21,811 22,878 24,929 77,379Grand Total

5,687 9,552 48,985 52,279 57,640 174,143

Medicaid Gender Age 0-9 Years Age 10-19 Years Age 19-34 Years Age 35-50 Years Age 50+ Years Grand Total

Female - 1 10 32 377 420 Male - 3 21 206 230

Grand Total - 1 13 53 583 650

54.33% of the Peach State Health Plan’s Medicaid population remains to be African American. Caucasians account for the second highest percentage of the population at 36.19%. Hispanic population decreased to < 0.5% from 1.05% at the end of 2016. Medicaid total membership decreased by 13% from 423,972 to 367,466 members. Ambetter membership increased by 41% ending the 2017 year at 114,519 compared to 67,891 membership at the end of 2016. Medicare population also increased from 403 members at the end of the year 2016 to 469 members at the end of 2017.

Barriers • Continued disparities in quality measures of care and access to care among Blacks and Hispanics

as compared to Whites. • Blacks and Hispanics continue to have less access to and utilization of care than Whites

Overall, the intervention designed to inform physicians about disparity on the PSP website is ineffective due to very few touches as compared to overall traffic. There were only 207 page views of the Cultural Competency Evaluation (0.01% of 2,060,923 website views) a 38% decrease from 2017 (331 page views). The National Healthcare Disparities Report (NHDR) focuses on “prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations” (42 U.S.C. 299a-1(a)(6)). Therefore, data summaries are provided below to facilitate comparison of these factors. Links to summaries of all individual quality measures are available at http://www.ahrq.gov/

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Measures by Race and Ethnicity for the State of Georgia

Far away from benchmark - the value for a measure has not achieved 50% of the benchmark.

Close to benchmark - the value for a measure is between 50% and 90% of a benchmark (i.e., worse than the benchmark but has achieved at least half of the benchmark but not as much as 90% of a benchmark).

Achieved benchmark or better - the value for a measure is no worse than 90% of the benchmark value, the measure has achieved the benchmark. This category also includes the case in which the measure’s value is equal to or better than the benchmark

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Linguistic Data 2017 Language Spoken by Medicaid Population

Language Count Mix %

English 323,691 91.60% Spanish 22,241 6.30%

No Linguistic Content 3,836 1.10% Unknown 2,142 0.60%

Arabic 598 0.20% Vietnamese 301 0.10% Portuguese 150 0.00%

Russian 148 0.00% French 142 0.00%

Miscellaneous (Other) 139 0.00% French Creole, Creole and Pidgins 62 0.00%

Italian 12 0.00% Hmong 11 0.00%

North American Indian Languages 6 0.00% Polish 5 0.00%

German 4 0.00% Creole - English 3 0.00%

Urdu 1 0.00% Tagalog 1 0.00%

Mandurian 1 0.00% Korean 1 0.00%

Finno-Ugrian (Other) 1 0.00% Dutch 1 0.00%

Armenian 1 0.00% Total 353,498 100.00%

Language Service Line Requests for Interpreters

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Top 3 Most Frequent Medicaid Requests

Table 5 - Language

2017 # of

Requests

2017 % Total

2016 # of

Requests

2016 % of Total

2015 # of

Requests

2015 % of Total

2014 # of

Requests

2014 % of Total

Spanish 4833 82.2% 5,261 72.18% 3,720 76.14% 1912 70.55%

Burmese 523 8.9% 276 3.78% 225 4.60% 165 6.09% Arabic 526 8.9% NA NA NA NA NA NA Nepali NA NA 89 1.22% 107 2.19% 107 3.95%

Top 3 Most Frequent Ambetter Requests

Language 2017 #Requests 2017 % Total Spanish 1948 53.4% Korean 938 25.7%

Mandarin 761 20.9%

Qualitative Analysis

Opportunities for Continuous Improvement Identified:

Spanish continues to be the most prominent non-English speaking language of PSHP’S membership and continue to show that members have a cultural and linguistic need for competence among practitioners and staff who interact with them.

Reinforce continuous improvement methods: • Monitor continued competence of bilingual staff • Continue tracking & monitoring of Language Service Line activities

Complaints To assess member experience, Peach State annually evaluates member complaints. Peach State Health Plan collects and analyzes data from all sources of members’ complaints and aggregates them into the following five categories:

• Quality of Care • Access • Attitude and Service • Billing and Financial Issues • Quality of Practitioner Office Site

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I. Grievances (Member Complaints) Peach State Health Plan defines a member complaint (grievance) as an expression of dissatisfaction about any matter other than an adverse benefit determination. An adverse benefit determination is a denial or limited authorization of a requested service, including the type, level of service, reduction, suspension or termination of a previously authorized service. The Quality Oversight Committee (QOC) has established a goal for grievances of ≤ 0.9 per thousand members, overall and by category and subcategory. Possible subjects for grievances include, but are not limited to, the quality of care or services provided, aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the enrollee’s rights. Peach State maintains an internal database system for the identification, acknowledgment, and prompt resolution of oral and written member grievances. Upon receipt of verbal or written complaints, each is assigned a category based upon the main issue in the complaint. Grievances with more than one issue identified, will have each issue investigated and the outcome of the investigation will address all issues identified on the grievance resolution letter.

Grievance Monitoring The Peach State Health Plan Quality Oversight Committee (QOC) monitors grievance data on a quarterly basis. This document summarizes all grievances received and the analysis for January 1, 2017 through December 31, 2017. Table 1 displays trended grievance data by major category for each measurement period.

Table 1: Trended Complaint Data by Grievance Category

Grievance Category

2017 (Measurement 3)

Total # Rec’d

Per K Member

% All Grievances

Billing & Financial

68 0.18/K ↓ 49.3%

Attitude & Service

54 0.14/K ↓ 39.1%

Access 11 0.03/K ↓ 8.0% Quality of Care 4 0.01/K ↓ 2.9%

Quality of Practitioner Office Site

1 0.00/k ↑ 0.7%

Total Number/ 1,000

138 0.36/K ↓ 100% 100%

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Grievance Subcategories Peach State categorizes grievances into major categories and then appropriate subcategories to allow for detailed tracking and trending and identification of opportunities. In the grievance tracking database, each major category is comprised of several subcategories to facilitate analysis of complaint issues. The following table details:

• the top two subcategories for each major category; • the percentage of the major category represented by the subcategory; and • the percentage of all grievances represented by each subcategory listed

Grievance Category Subcategory*

# and % of Total Complaints by

Each Category

% of All

Grievances by each

Subcategory

Complaints Per 1000

Members**

Goal: <0.9 Per 1000 Members Met: Y/N

2017

Billing & Financial

Member Billed by Provider/

Balance Billed50/ 73.5% 36.2% 0.130/k Y

Other Billing Issue 7/ 10.3% 5.1% 0.018/k Y

Attitude & Service Dissatisfied with Service

24/ 44.4% 17.4% 0.063/K Y

Rudeness of Provider Staff 9/ 16.7% 6.5% 0.023/k Y

Access Turned Away 7/ 63.6% 5.1% 0.018/k Y

Appointment Availability

2/ 18.2% 1.4% 0.005/k Y

Quality of Practitioner Office

Site

Office Cleanliness

(No Second Sub-category)1/ 100% 0.7% 0.003/k Y

Quality of Care Dissatisfied with Care/Treatment 4/ 100% 2.9% 0.010/k Y

*Sub-category includes only the top 2 sub-categories for each major grievance category ** Complaints per 1000 members include all sub-categories in the identified major grievance category

Analysis In the most recent measurement year (January 1, 2017- December 31, 2017), the percent of grievances increased in one of the six grievance categories (Quality of Practitioner Office Site) and the total grievances per 1,000 members decreased from the previous year from 0.88 grievances/1000 to 0.36 grievances/1000. The goal of <0.9 grievances per thousand members was met for all categories and subcategories.

The driver of the increase in ‘Quality of Practitioner Office Site’ was, Office Cleanliness, increasing 0.7 percentage points from 0% (2016) to 0.7% (2017). This subcategory only representing 0.7% of all the grievances received in the current measurement period.

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Opportunities for Continuous Improvement Identified: Goal: Continue to heighten cultural competency and awareness while increasing awareness of health disparities among staff and providers.

Healthy People 2020 continues to stress that health professionals must recognize the impact that social determinants have on health outcomes of specific populations—and be aware of the disparities they create. If a health outcome is seen to a greater or lesser extent between populations, there is disparity. Race or ethnicity, sex, sexual identity, age, disability, socioeconomic status, and geographic location all contribute to an individual’s ability to achieve good health.

Objective: To continue to make health care disparity information available and accessible to all network physicians, on-going

Objective: To continue contribution to reducing GAP in provision of quality health care between African and European Americans

Objective: To increase staff and provider awareness and understanding of LGBT cultural barriers by year end 2018 – To be continued

Continue Interventions in 2018:

Staff and Network Provider Focused: • Intervention: Include assessment and understanding of the LGBT Community and health barriers in

the Cultural Competency trainings - Compliance

Member Focused: • Continue to manage programs; monitor and collect HP data outreach re: HIV/AIDS and Diabetes.

Collect: o Program Participation rate o Readmission Rate o Compare results at year end to prior year

• Obtain total number of members with a diagnosis of Diabetes Mellitus for all LOBs (QI) • Obtain count of all members obtaining REE – all products

o Identify Number of AA members with DX of Diabetes - Medicaid AA members obtaining REE

o Identify Number of EA Members with DX of Diabetes – Medicaid EA members obtaining REE

• Track the number of AA Diabetic members obtaining Retinal Eye Exam, quarterly, alongside the number of EA Diabetic members obtaining Retinal Eye Exam

• Compare totals: 2018 data results to data obtained in 2018

Provider Focused: • Inform providers about the availability and utilization of disparities data @ http://www.ahrq.gov/

o Consider a physician e-blast to heighten awareness access and location to disparity and cultural competency information.

o Include report re: number of Web hits in 2017

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Recommendations:

• Sustain achievements from 2017 • Sustain efforts to reduce the health care disparity gap in provision of quality health care between

African and European Americans • Continue to monitor and maintain HP data outreach re: HIV/AIDS and Diabetes in 2018 • Sustain Continuous Improvement methods and tools to identify opportunities for improvement

o Track all on-going Cultural Competency outreach & outcomes per department to allow for on-going continuous improvement

o Include all lines of business: Medicaid, Ambetter & Medicare o Continue tracking of CCP training as conducted annually for all providers, PSHP staff, and

new hires (providers and staff) during on boarding process. o Continue Cultural Competency Committee meetings, quarterly

Reference:

A Physician's Practical Guide for Culturally Competent Care has been updated! In April 2013, the National CLAS Standards were re-released after undergoing a two-year enhancement initiative. The content of this program has been updated to include the updated National CLAS Standards, more interactivity, and updated literature and references!

The Affordable Care Act (ACA) advances efforts to reduce disparities and to improve health and health care for vulnerable populations.