Quality Improvement, Physician Advisory, Peer Review, and Credentialing Committees Meeting Thursday, October 8, 2015 7:30 – 9:00 AM th 50 Beale Street, 13 Floor
Dial in Information: Dial +1 (646) 749-3131 Access Code: 147-628-493 Audio PIN: Shown after joining the meeting Meeting ID: 147-628-493 https://global.gotomeeting.com/join/147628493
AGENDA Quality Improvement Committee: Open Session Tab
Time
1
7:30
2
7:35
Topic
Objective
Follow Up Items (5 min)
Update
QIC: quorum: 5 QIC members, 3 physicians, including committee chair
•
• Public Comments/Questions • DHCS CAP Update • Review Follow Up Items (p 3) Consent Calendar (5 min)
Update / Vote
• • • •
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7:40
Review of Minutes – August 13, 2015 (p 4) CMO Update (p 13) Member Report (p 22) Members of Pharmacy & Therapeutics Committee (p 27) • Policies & Procedures (p 29) o HE-02 Initial Health Assessment o Pharm-01 Pharmacy & Therapeutics Committee o Pharm-02 Pharmacy Prior Authorizations o Pharm-10 PGY1 Managed Care Pharmacy Residency Program o Pharm-13 After Hours Pharmacy Access o QI-06 Member Grievances and Appeals o UM-03 Organ Transplants o UM-22 Authorization Requests o UM-38 Durable Medical Equipment o UM-48 Repatriation • UM Committee Minutes o August 2015 (p 31) o September 2015 (p 37) Policies and Procedures (15 min)
Vote
• • •
Vote
Summary (p 44) QI-05 Timely Access Standards (p 45) Pharm-14 Formulary Exclusions, Limits &
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Assigned Dr. Glauber
Dr. Glauber
J. Soos
Quality Improvement, Physician Advisory, Peer Review, and Credentialing Committees Meeting Thursday, October 8, 2015 7:30 – 9:00 AM th 50 Beale Street, 13 Floor
Dial in Information: Dial +1 (646) 749-3131 Access Code: 147-628-493 Audio PIN: Shown after joining the meeting Meeting ID: 147-628-493 https://global.gotomeeting.com/join/147628493
AGENDA Quotas (p 51) 4
7:55
Quality Improvement (20 min) • • •
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8:15
8:30
Update Update Update
A Jaffe J. Strange N.Ylagan/K. McDonald
Update
S. Dongre
Provider Network Operations (15 min) •
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Health Services Scorecard (p 55) CAHPS 2015 Survey Results (p 58) Q2 2015 Grievance Report (p 61) o Including Appeals (p 68), State Fair Hearing (p 74), Independent Medical Reviews (p 76)
Provider Satisfaction Survey Results (p 78)
PAC
NEXT MEETING THURSDAY, DECEMBER 10TH
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Quality Improvement Committee Follow Up List QIC Meeting Date
Follow Up Item
Owner
Complete By
Status
January 2015
Submit to committee the infant mortality rate between African American and Caucasians
S. Weis
2/12/15
Completed
February 2015
Can SFHP's pharmacy dept be able to approve non-formulary medications when the member is in the ED?
N. Ylagan
3/4/15
Completed
February 2015
For investigations that involve PQIs, can SFHP turnaround times match SFGH's turnaround times?
J. Soo
6/11/15
Completed
April 2015
Where can Healthy Workers go for a 24/7 pharmacy if need be?
N. Ylagan
6/11/15
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 class 3. All medications in the seizure drug class 4. All medications for treatment of Hepatitis B 5. All antibiotics ** 6 days supply is allowed for fentanyl SFHP contacted SFGH's Director of Quality Management but didn't a response. Walgreens: 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 proces 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 clinica 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
Completed
By the December QIC, a timely access regulation dashboard presented to QIC and a one pager of information of all the timley 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
Completed
The 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.
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Comments Submitted to the committee on 2/12/15
Quality Improvement Committee Minutes
Date: Meeting Place: Meeting Time: Present: Staff Present:
Topic
Call to Order
Discussion [including Identification of Quality Issue] • • •
Follow Up Items
August 13th, 2015 San Francisco Health Plan, 50 Beale Street 12th floor, San Francisco, CA 94105 7:30-9:00 am Irene Conway, Edward Evans, Albert Yu, MD; Todd May, MD; Jeffery Critchfield, MD; Shawna Lamb James Glauber, MD; Fiona Donald, MD; Anna Jaffe, Kirk McDonald, Mimi Zou, Maika Hefflefinger, Jim Soos, Nicole A. Ylagan, Gabrielle Torres, Cassandra Caravello
• • • •
Meeting was called to order at 7:40 am Items that did not require a vote were presented until there was a quorum Meeting was called to order with a quorum at 8:00 am There were no public comments Reviewed follow up items regarding Beacon The committee was provided a packet regarding Beacon services and membership across the nation The Survey Monkey sent to the committee showed approval of extending QIC to 1 and 1/2 hours. This will start in October
Follow-up [if Quality Issue identified, Include Corrective Action] • No follow up needed
•
n/a
•
•
n/a
No follow up needed
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Resolution, or Closed Date [for Quality Issue, add plan for Tracking after Resolution]
• Consent Calendar
Blood Pressure Cuffs are now a SFHP Pharmacy benefit. The consent calendar was reviewed and approved unanimously. • Review of Minutes – June 11, 2015 • CMO Update • Member Report • Pharmacy Updates o P&T Minutes - July 15, 2015 o Policies & Procedures CLS-03 Member Advisory Committee o CLS-05 Health Education Standards o Pharm-01 Pharmacy & Therapeutics Committee o Pharm-07 Emergency Med Supply o QI-06 Member Grievances and Appeals o UM-01 UM Notice of Action Letters o UM-12 Emergency Medical and o Psychiatric Services o UM-29 Behavioral Health Services • UM Criteria o Hayes o InterQual revisions 2015 • UM Committee Minutes o June 2015 o July 2015 • SFHP adopted InterQual Criteria and Hayes Directory - a decision made by UM Committee to use. • InterQual Criteria approved by the UM Committee: Acute Care, Subacute/ Skilled Nursing Facilities, Long Term
•
No follow up needed for the consent calendar.
Entire Consent Calendar approved Approved P&P’s: o CLS-03 o CLS-05 o Pharm-01 o Pharm-07 o QI-06 o UM-01 o UM-12 o UM-29
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•
• Policies and Procedures
•
Acute Care, Durable Medical Equipment, Home Care, Imaging, and Procedures Jim informed the committee that UM Criteria will no longer be primarily reviewed by QIC. UM Criteria will now be evaluated by the UM Committee. QIC will instead approve actions of the UM Committee. UM Committee minutes will be on consent calendar and reviewed/ approved by QIC. Committee- motion to approve UM-57 UM Clinical Criteria o This policy defines how we adopt UM criteria and the clinical criteria hierarchy o UM- 57 provides clarification and transparency of UM clinical criteria o SFHP is required to use (State/Federal and (Medi-Cal/CMS) standards for criteria when applicable o Delegated medical groups can use other criteria as long as they are evidence-based and applied consistently. o In terms of application hierarchy, SFHP requires that providers apply them in order. o The policy also addresses the review and adoption process: UM Committee reviews criteria, makes a
•
.No follow up needed
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Approved: o UM-57 o UM-22 o UM-02
recommendation, and brings it to QIC for final approval. Q: Do you use Hayes for questions that cannot be answered by InterQual? A: Yes, we use Hayes to supplement InterQual, particularly with respect to new technology • UM-22 Authorization Requests o Clarifies procedure for Prior Authorizations (PA) o Addresses/ integrates NCQA requirements o Procedure for submitting nonemergent requests has now been changed to 14 days. o SFHP is notifying providers of PA authorization via fax, email, phone, etc. o CPMC inpatient admission notification timeline has been altered o Policy clarifies notification requirement for SFGH authorizations o Clarification of external medical review and turnaround times o Clarifies member inbound communications o Describes the role of the UM Committee • UM-02 Medi-Cal and Dual Eligible Members Admitted for LTC & SNF o Combines two current SNF/long-
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HEDIS Results
• • • • •
•
•
•
term care policies so we now have one Committee- motion to approve • Cassie presented SFHP Medi-Cal HEDIS Results- Measurement year 2014 Cassie presented a graph showing the number of SFHP measures reaching the national 90th percentile for Medicaid 48% of publicly-reported measures are better than 90% of other Medicaid plans in the country. Reached the 90th percentile in 50% of auto assignment measures. High performance in auto assignment measures can increase the rate of members who don’t pick a plan that are enrolled in SFHP. SFHP currently has the highest auto assignment rate in the state Measures in the Medical 90th percentile nationally: Controlling Blood Pressure, Well Child visits, Childhood Immunizations, Weight Assessment and Counseling for Nutrition and Physical Activity, Imaging studies for lower back pain, Comprehensive Diabetes Care Measures in the 75th percentile: Comprehensive Diabetes Care (A1c screening), Cervical Cancer Screening, and Prenatal and Postpartum Care Measures in the 50th percentile: Immunizations for Adolescents, Labs for Patients on Persistent Meds,
.No follow up needed
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•
n/a
•
Medication Management for people with Asthma, and Children and Adolescents Access to PCPs. These measures are generated from claims/encounter data only SFHP is improving our HEDIS performance by: o Practice Improvement Program o Ongoing member gift card incentives:– Hypertension, Well Child visits, Diabetes, Childhood Immunizations, Prenatal and Postpartum Care o Disease management program launch (asthma and diabetes) o Data quality improvements – capitated system that makes this difficult to do; PIP data quality domain o Eventual Full NCQA accreditation – Will require reporting 13 additional HEDIS measures. This requires new measure benchmarking; SFHP hasn’t previously reported behavioral health measures and will need to work with Beacon and CBHS to obtain needed data o Disparities analysis and interventions – SFHP is participating in disparities leadership program;
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•
Disease Management
• •
this year the HEDIS team will be doing more quantitative data collection to highlight our underlying racial/ethnic disparities (i.e. Postpartum care was a an area with large disparity last year) Cassie is finalizing the memos that will be sent to each medical group highlighting their group-specific HEDIS results Mimi and Dr. Donald presented information on Disease Management (DM) Q-13 Disease Management o Development guided by NCQA Quality Improvement Standards o This program will be launched in Spring 2016 and is open to all lines of business (excluding Kaiser and HSF) o The DM programs are aligned with nationally recognized evidencebased clinical practice guidelines o Asthma and Diabetes were selected as the two chronic conditions based on high prevalence among our membership, identified gaps in performance measures (low HEDIS rates) and potential for high impact/improvement on patient clinical outcomes. o Currently using claims and
•
No follow up needed
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Approved: Q-13
• • •
encounter data (including pharmacy data) to identify members who qualify for the program o SFHP informs eligible members about the DM programs through member newsletters, direct outreach, and through the Member page of the SFHP website. o SFHP’s Disease Management (DM) programs address condition monitoring, patient adherence to treatment plans, medical and behavioral health co-morbidities, health behaviors, psychosocial issues o For both programs SFHP has stratified membership into 3 risk categories (1 – low acuity to 3- high acuity); each acuity level receives a targeted intervention o Stratification can change over time and members are re-stratified o We will also be tracking active member participation rate, member experience, and other areas for program evaluation Committee approved both ICSI clinical practice guidelines for Diabetes and Asthma Reviewed provider website and notification content with no additional comments. Motion to approve policy & procedure
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QI-13 with no edits.
QI Committee Chair's Signature & Date: 9/1/15 Minutes are considered final only with approval by the QIC at its next meeting.
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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:
September 21, 2015
To:
Quality Improvement Committee
From:
Jim Glauber, MD, MPH Chief Medical Officer
Regarding:
CMO Report for September 2015 Meeting
LOCAL, STATE & FEDERAL UPDATE San Francisco Health Commission Approves “Bridge to Coverage” On August 4th, the San Francisco Health Commission approved the Department of Public Health (DPH) proposal to modernize the City Option program and explore the creation of an Employee Wellness Fund. The approved proposal includes the following two key modifications to the City Option program and Healthy San Francisco, both of which the San Francisco Health Plan (SFHP) will serve as the third party administrator: 1. Creation of a new “Bridge to Coverage” program (3000 City Option employees estimated to be eligible) to make health insurance offered through Covered CA more affordable for eligible City Option employees. • To be eligible, employees must a) receive contributions from an employer through the City Option; b) have incomes up to 500% FPL; and c) reside in San Francisco. • The “Bridge to Coverage” benefit is based on income level and includes additional premium and cost-sharing assistance in excess of the federal subsidy to assist individuals with purchasing affordable health insurance through Covered California. 2. Changes to Healthy San Francisco (HSF) program eligibility to make health care more affordable for participants, most of whom, because of documentation status, are ineligible to purchase health insurance through Covered CA. • The HSF upper income eligibility limit will increase from 400% to 500% FPL. The latter figure was the previous HSF income limit prior to a policy change enacted by the DPH in January of 2014 when federal health reform took effect. • Establishes a permanent extension allowing HSF participants eligible for subsidy through Covered CA to remain in HSF if they cannot afford to purchase insurance through Covered CA. • Allows San Francisco residents ineligible to purchase insurance through Covered California, exempt from the individual mandate due to financial
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hardship or whose options for health insurance are unaffordable, to enroll and participate in HSF. The DPH proposes that all of these HSF and City Option program enhancements and changes be operationalized by the SFHP beginning late 2015-16. The DPH also proposes exploration of an Employee Wellness Fund, to implement programs that improve employee health status and reduce associated employer costs, using City Option employer reimbursements. Through stakeholder engagement and future discussions with employers, DPH will explore the feasibility and logistics for implementing an employee wellness fund. We will continue to keep the board apprised as SFHP begins the significant work associated with operationalizing the “Bridge to Coverage” program. Special Legislative Session on Medi-Cal Funding Ends without Agreement on Managed Care Tax On August 17, the Legislature reconvened from its summer break and has until September 11 to complete its work for the calendar year. Separately, upon signing the State budget in June, the Governor called for two extraordinary sessions (often referred to as “special session”): the first is for transportation and infrastructure development and the second is to address Medi-Cal financing issues, specifically the replacement of the managed care tax for Medi-Cal, funding for Medi-Cal providers and developmental services providers, and funding for restoring the 7% reduction in hours of In-Home Supportive Services (IHSS) workers. As you recall, the Governor had included in his January and May Revision budget proposals for the imposition of a broad based $1.3 billion tax on all managed care plans in California (commonly referred to as the MCO tax) to replace the prior MCO tax that did not meet federal requirements, largely because it was targeted to managed care plans that participated in Medi-Cal, not all managed care plans operating in the state regardless of participation in Medi-Cal. The current MCO tax sunsets July 1, 2016. The new MCO tax would fund $1.1 billion in general Medi-Cal expenditures and also pay for a $226 million cost associated with the restoration of IHSS service hours. Because a new MCO tax requires a 2/3 vote and there is no consensus yet between legislative Democrats and Republicans, the Governor’s replacement MCO tax has not passed. Establishing a special session allows the Legislature to bypass the normal legislative deadlines to gain extra time to consider and pass a replacement MCO tax prior to the July 1, 2016 deadline. It is unlikely that a replacement tax will be passed in the coming months even in special session until the Brown Administration finds additional incentives for those commercial managed care plans that do no Medi-Cal business and would be subject to the tax to be willing to pay the tax. The legislature was unable to reach agreement on a new managed care tax proposal by the September 11 closure of the special session.
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Lastly, the state budget also included funding to expand Medi-Cal to undocumented children, effective no sooner than May 2016. SFHP is excited about this expansion to Medi-Cal that will provide eligible undocumented children with full-scope Medi-Cal. California Children’s Services Program Changes Unveiled by DHCS In mid-June, the DHCS released a proposal that would redesign the California Children’s Services (CCS) program. http://www.dhcs.ca.gov/services/ccs/Documents/WholeChildModel.pdf CCS provides diagnosis, treatment, and case management to children under age 21 who have complex medical needs. The majority of CCS enrollees are Medi-Cal eligible, with a small percentage of CCS enrollees eligible only for CCS services and paid for by the counties. Under current law, the CCS program is carved out of Medi-Cal managed care, meaning that CCS services are provided on a fee-for-service basis, and CCS eligible children receive services related to their CCS eligible condition through the program, but receive other health care services through Medi-Cal managed care. This carve-out expires at the end of 2015. The DHCS has been interested for several years in better coordinating and integrating other health care services with CCS services, and the DHCS currently has statutory authority to operate pilot projects for “whole child” care where CCS services are integrated into Medi-Cal managed care. The department has been engaged in a stakeholder process over the last several months to come to some consensus on a whole child care model of services for CCS. The proposal released by the DHCS in June would, over time, phase in CCS services to Medi-Cal managed care. The first phase would carve in CCS services in County Organized Health Systems counties and up to 4 counties with Two Plan models no sooner than July 2017. If successful, model would expand by 2019 to the remaining counties. Several organizations have signaled their opposition to the DHCS proposal. Should the DHCS decide to alter its proposal, there is legislation pending that could extend the CCS carve out for whatever amount of time the Brown Administration determines it is willing to agree to that can be passed in time to take effect prior by January 1, 2016. We will continue to keep you updated on this issue as it moves forward.
SAN FRANCISCO HEALTH PLAN STRATEGIC ANCHORS Goal 1: Universal Coverage Healthy San Francisco Program Enrollment as of July 31, 2015
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Total Enrollment A total of 15,202 participants were enrolled in Healthy San Francisco as of July 31, 2015. The City Option Program continues to grow and recent DPH policy and HCSO changes will spur further growth (see discussion of “Bridge to Coverage” program above) with 2,489 employers offering $4.8M City Options contributions and 183,207 employees receiving benefits since inception. Covered CA Enrollment Site In July, SFHP was approved to become Certified Medi-Cal Managed Care Plan Enrollment Entities. SFHP enrollment and outreach staff have completed the background screening portion of the application process and will undergo training next. Upon completion of the training, they will be scheduled to take the certification exam. The target date for completion is late October, with the hope of beginning enrollment by early November. The target audience for enrollment assistance will be HSF participants and Medi-Cal members that may be transitioning out of those programs.
SFHP MEMBERSHIP UPDATE As of July 2015, global membership increased by 1.85% (2,536 members) from June 2015 to July 2015; and increased by 18.4% (21,760 members) since July 2014. Global membership is 2.38% above goal (3,249 members).
Medi-Cal Expansion Updates As of August 1, 2015, SFHP active enrollment in the Medi-Cal expansion-related aid codes is 54,084 members. SFHP remains compliant with the requirement mandated by AB 85 to default 75% of non-choosing members to primary care providers within the public hospital system. In July and August over 1800 non-choosing members were defaulted to the public hospital system.
STRATEGIC ANCHOR 2: QUALITY CARE & ACCESS HEALTH SERVICES The Clinical Operations department continues to enhance its operations by improving workflows and training staff to meet the goals of multiple ongoing initiatives. In Q2 2015, the department focused on the NCQA mock-audit, DHCS/DMHC Medical Audit, and ICD-10 preparation.
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Utilization Management Utilizing the NCQA Interim Accreditation requirements, Clinical Operations prepared its policies, procedures, and desktop processes to be evaluated by SFHP’s NCQA consultant in a mock-audit. As an organization, SFHP met the minimum requirements to be considered Interim Accredited, although a score of “0” was provided to Clinical Operations for its policy to adopt DHCS’ turnaround time versus NCQA. DHCS mandates the use of their turnaround times for processing authorizations and they are not completely aligned with NCQA. To mitigate receiving a “0” score when actual submission occurs to NCQA, SFHP will create a communication to the NCQA Board stating that mandated regulations supersede the NCQA requirements. In March, SFHP underwent a joint DHCS/DMHC Medical Audit that uncovered several opportunities for improvement. SFHP is awaiting the final report from DHCS and DMHC, but in the interim, there are several process enhancements that can be implemented prior to the final Corrective Action Report. Implementing these processes now will position SFHP to have greater resources for the longer term issues, show evidence of expeditious decision making, and provide better access to services for members and providers. One of these changes is the implementation of a Utilization Management (UM) Committee. This entity has the responsibility for evaluating all UM activities to ensure the process meets regulatory and compliance requirements in addition to evaluating the quality of services provided by UM staff. One of the first decisions made by the UM Committee was the selection of over and underutilization benchmarks in which both SFHP and Delegated Medical Group’s UM metrics and performance would be measured against. These changes will continue throughout the fiscal year and will be reevaluated by DHCS and DMHC around March 2016. The Clinical Operations department is also preparing for ICD-10. Our care management system, Essette, has been recently updated to accept ICD-10 codes and computer-based training has commenced. Within team meetings and at the department level, ICD-10 is being socialized almost daily and there is a high level of comfort with the authorization staff. Cross-functionally, Clinical Operations is working with Training, Business Intelligence, Provider Network Operations, Operations, and ITS to create a smooth transition both internally and externally with our customers. Health Improvement HEDIS SFHP is pleased to announce its final HEDIS rates for MY 2014. The organization exceeded its goal by reaching 48% of publicly reported measures in the 90th percentile (46% was the target), and no measures below the 25th percentile. Of the 16 hybrid (claims/encounter data plus chart review) HEDIS measures in the Department of Health Care Services (DHCS) External Accountability Set, SFHP has reached the national Medicaid 90th percentile in 11. One of the hybrid measures in the 90th percentile is the Controlling High Blood Pressure measure, which became a DHCS auto assignment measure in late 2014. SFHP attributes some of its success in this
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measure to the new member incentive program for members with hypertension that was launched in November of 2014. SFHP has also reached the 90th percentile in two of the 11 administrative (claims/encounter and supplemental data only) measures required by DHCS. Last fall SFHP received the 2014 HEDIS Bronze Quality Award from the DHCS based on its HEDIS Measurement Year (MY) 2012 results. On September 17 DHCS released its latest managed care Performance Dashboard and SFHP retained its third position on aggregated HEDIS scores, surpassed only by Kaiser Northern California and Kaiser San Diego. Population Health Management Currently, SFHP is finalizing the development of its new Disease Management (DM) program. SFHP has identified asthma and diabetes as the two chronic conditions relevant to its membership and in need of improvement based on MY2013 HEDIS rates. The program stratifies members into three strata based on diagnosis, and utilization patterns. Each stratified group will receive targeted interventions appropriate for its level of acuity. A suite of new health education material has also been developed for both chronic conditions. SFHP is contracting with CareNet Healthcare Services to provide live outreach and assessment calls to members in the program. For both diabetes and asthma, the new DM program will align with SFHP’s existing interventions (e.g. HEDIS incentives and the Diabetes Texting and Asthma Texting program). The DM program is projected to launch March 2016 and will manage the care of over 2,000 Members with Asthma and over 6,000 members with Diabetes. In addition, SFHP has identified key areas for HEDIS improvement and will be launching outreach strategies in 2015 to improve those rates. These measures include Cervical Cancer Screening, Immunizations for Adolescents, and Prenatal and Postpartum Care. SFHP is also beginning monitoring and analysis of HEDIS measures (those not currently reported) that will be required for eventual full NCQA accreditation. Access Improvements In addition to the increased emphasis on primary care access in the Practice Improvement Program measure set, Health Improvement has developed several measures that address SFHP’s low member satisfaction with specialty access. All of the delegated medical groups will participate in the additional measures, including appointment availability and patient experience. SFHP is also expanding internal measures for access monitoring, per the most recent DHCS/DMHC audit. Key measures include network adequacy and primary care and specialty visit utilization rates. These measures will assist with prioritizing SFHP’s improvement activities. Member Satisfaction Every three years, DHCS measures member satisfaction via Health Plan CAHPS, in which SFHP consistently performs poorly. In order to monitor improvements more consistently and tailor the report presentation, SFHP now conducts this survey every
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year, independently from DHCS. Our recent results show that scores remain low, though we are optimistic that scores will improve as several provider groups have requested assistance with improving access scores. SFHP will be disseminating the HP-CAHPS results to specific provider groups this fall, when we meet with provider groups’ leadership to discuss performance in both HEDIS and CAHPS and how SFHP can best support them in their improvement efforts. Care Coordination As of August 2015 the Community-Based Care Management (CBCM) CHAMP Demonstration Project is in process of submission of the 4th Quarter Status Report to the California Health Facilities Financing Authority (CHFFA) and continues successful progression on the project schedule. The CBCM project completed the following new activities: • Completion of the iPad pilot: A pilot evaluation is in process and the decision to expand iPad access for entire Care Coordination team will be made by end of August 2015. iPads are used in the field by Coordinators to expedite documentation and provide access to member health plan documentation. • Advancement of preliminary data collection and analysis: A draft comprehensive evaluation of the CareSupport Program will be completed in January 2016. The evaluation will include member satisfaction, member self-efficacy, member reported health, and several utilization measures such as number of hospitalizations, number of bed days, number of ED visits, and number of primary care visits. • Successful distribution, collection, and analysis of CBCM Client Satisfaction Survey: The survey had a 63% return rate with 96% who respond "yes" CareSupport was helpful. In addition the survey solicited qualitative input. One member stated, "San Francisco Health Plan seems to be meeting the healthcare needs, practical support, and cultural concerns of the clients. Karina has been especially patient, understanding, and emotionally supportive. She does a great job identifying areas of my health that require my involvement.” Another member summarized CareSupport efforts in stating, "The members of your CareSupport program have been so helpful in providing advice guidance encouragement and help at this time when I needed it most. I am so thankful to have professional people in my life like yourself. I can see how you can be a valuable asset to anyone's life, especially if they are having personal or health problems. I hope you will continue to enrich other peoples’ lives as you have mine.” Pharmacy Update Our second Post-Graduate Year 1 Pharmacy Resident, Dai Tan, started in 7/15 and has quickly integrated with the pharmacy team and the work. We continue recruiting for a new Director of Pharmacy. In July SFHP began offering ePrescribing through Surescripts to network providers who have this capability through their EMRs. EPrescribing offers the following benefits: • Prescription Benefit: The Prescription Benefit service puts eligibility, benefits and formulary information immediately available to physicians at the time of
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•
•
prescribing. This enables prescribers to select medications that are on formulary and are covered by the patient’s drug benefit. It also informs prescribers of lower cost alternatives such as generic drugs. Prescription History: Prescribers can access a timely and clinically sound view of a patient’s prescription history across providers at the point of care. This decreases the risk of preventable medication errors. Prescription Routing: Prescription Routing replaces old, error-prone approaches to sending new prescriptions with the secure computer-to-computer exchange of prescriptions between prescribers and pharmacies. Routing new prescriptions electronically reduces the risk of medication errors associated with poor handwriting, illegible faxes and manual data entry. Using Prescription Routing to process prescription renewals saves time and money by reducing the number of phone calls and faxes typically associated with the prescription renewal authorization process.
In response to a draft US Preventive Services Task Force Recommendation strongly endorsing the use of ambulatory blood pressure monitoring in the diagnosis and management of high blood pressure (hypertension), in August SFHP began covering home blood pressure cuffs through our pharmacy benefit. In July, SFHP transitioned to a new Pharmacy Consultant: Excelsior Solutions, whom we believe will provide more engaged and effective support to our internal clinical pharmacy program and in optimizing our relationship with our PBM, PerformRx. On July 1st, DHCS implemented a revised the DHCS Treatment Policy for Hepatitis C. The new policy is more liberal than the previous policy and SFHP has already seen a marked increase in the number of patients qualifying for treatment with these highly effective, but high cost antivirals (Sovaldi, Harvoni, Viekira Pak). In June, prior to the new policy implementation, 16% of total pharmacy spending was on Harvoni and Sovaldi and comprises 12% of total pharmacy spending since 1/15. Our June 15th, Hepatitis C spending was 85% higher than that in 11/14. DHCS has reduced the weekly kick payment rate for Hepatitis C medications by 9%, heightening the fiscal challenges imposed by this medication class. Additionally, a new class of highly effective cholesterol lowering medication, so-called PCSK-9 inhibitors: Pravulent was approved in July and Rapatha was approved in August. Unlike the widely generically available (and affordable) statin class of medication, the PSCK-9 inhibitors cost over $14,000/year. And unlike the Hepatitis C medications, which typically are required for 12 weeks to achieve a cure, the PCSK-9 inhibitors may need to be taken lifelong to achieve effective cholesterol reduction. It is unknown at this time whether DHCS will offer a kick payment for these medications.
ANNUAL EMPLOYEE SURVEY
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SFHP conducted its sixth annual employee survey in April 2015. This year we had an 84% response rate which largely eliminates the possibility of a non-response bias. Positive ratings of overall satisfaction are average and remain essentially unchanged since 2011. Overall, 79 measures saw increases and 22 of those are significantly higher. Overall satisfaction was 58% in 2015, compared to 51% in 2014. The following are key strengths among employees that were identified in the survey: • Pride in working for SFHP • Understanding of how our work contributes to SFHP’s goals • Belief that we are contributing to SFHP’s mission • Willingness to go above and beyond for the company • Having a respectful supervisor The following are key opportunities for improvement: • Executive team has some areas for improvement including, leading by example, creating a positive work environment, and not playing favorites. • Holding employees accountable for their actions • Initial Training • Communication between departments We are developing and have implemented a number activities and infrastructure improvements to address these areas.
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Membership Report - August 2015 Department: Marketing & Communications Global membership increased by 1.13% (1,586 members) from July 2015 to August 2015; and increased by 19.8% (23,346 members) since August 2014. Global membership is 3.54% above goal (4,835 members). Medi-Cal (MC): Membership increased by 1.33% (1,671 members) from July 2015 to August 2015, and increased by 23.3% (24,086 members) since July 2014. SFHP retains 84.8% (123,351 members) of MC market share in SF County. Medi-Cal membership is above goal by 1.37% (5,539 members). Healthy Workers (HW): HW membership decreased 0.37% (44 members) from July 2015 to August 2015, and decreased 4.60% (565 members) since August 2014. Membership is below goal by 0.36% (538 members). Healthy Kids (HK): Membership decreased by 2.01% (41 members) from July 2015 to August 2015, and decreased by 8.06% (175 members) since August 2014. Membership is below goal by 11.29% (254 members). San Francisco continues to have a small and decreasing population of families and children which reflects in the low overall numbers. SFHP is developing a marketing/outreach strategy for new ways to reach out to potential members and increase the annual renewal rates of existing members through internal outreach efforts.
* Source: www.dhcs.ca.gov/dataandstats/reports
22
Global Membership MC HW HK Total Net New % New
Sep-14 112,968 12,265 2,174
Sheet 1 Oct-14 116,154 12,192 2,178
Nov-14 119,412 12,191 2,166
Dec-14 121,166 11,876 2,122
Jan-15 119,265 11,837 2,091
Feb-15 120,514 11,839 2,094
Mar-15 120,544 11,821 2,097
Apr-15 121,743 11,792 2,067
May-15 122,707 11,826 1,980
Jun-15 123,429 11,801 2,036
Jul-15 126,003 11,762 2,037
Aug-15 127,674 11,718 1,996
127,407 4,166 3.66%
130,524 3,117 2.45%
133,769 3,245 2.49%
135,164 1,395 1.04%
133,193 -1,971 -1.46%
134,447 1,254 0.94%
134,462 15 0.01%
135,602 1,140 0.85%
136,513 911 0.67%
137,266 753 0.55%
139,802 2,536 1.85%
141,388 1,586 1.13%
117,328
118,952
121,136
123,081
124,914
126,126
126,940
127,752
128,408
129,061
136,146
136,553
Aug-15 Aug-14 Change
141,388 118,042 23,346
19.8%
Medical Group SFCCC + DPH NEMS NMS CCHCA UCSF HILL KAISER BTP Unassigned Total
# 68,212 32,317 1,748 11,031 11,092 4,676 7,806 4,503 3 141,388
% 48.2% 22.9% 1.2% 7.8% 7.8% 3.3% 5.5% 3.2% 0.0% 100.0%
Language English Chinese Spanish Others Russian Vietnamese Total
# 67,564 45,705 18,577 3,903 2,426 3,213 141,388
% 47.8% 32.3% 13.1% 2.8% 1.7% 2.3% 100.0%
Key: = Actual ; ▲ = Goal
148,000 138,000
133,769
135,164
130,524
133,193
134,447
134,462
135,602
136,513
137,266
136,146
127,407
128,000 118,000 117,328
139,802
118,952
121,136
123,081
124,914
126,126
126,940
127,752
128,408
108,000 98,000 88,000 78,000 68,000
23
129,061
141,388
136,553
Annual Growth
Medi-Cal (MC) Membership Net New % New
Sep-14 112,968 4,175 4.20%
Oct-14 116,154 3,186 2.82%
Sheet 1 Nov-14 119,412 3,258 2.80%
Dec-14 121,166 1,754 1.47%
Jan-15 119,265 -1,901 -1.57%
Feb-15 120,514 1,249 1.05%
Mar-15 120,544 30 0.02%
Apr-15 121,743 1,199 0.99%
103,356
104,966
107,136
109,067
110,830
112,033
112,838
113,641
Key: = Actual ; ▲ = Goal
132,000 119,412
122,000
121,166
123,429 121,743 122,707 119,265 120,514 120,544
116,154
121,725
112,968
112,000 102,000
103,356
104,966
126,003
107,136
109,067
110,830
112,033
112,838
113,641
114,287
92,000 82,000
114,931
May-15 122,707 964 0.79%
Jun-15 123,429 722 0.59%
Jul-15 126,003 2,574 2.09%
Aug-15 127,674 1,671 1.33%
114,287
114,931
121,725
122,135
Aug-15 Aug-14 Change
127,674 103,588 24,086
23.3%
Medical Group SFCCC+ DPH (aka CHN) NEMS NMS CCHCA (aka CHI) UCSF Hill Kaiser BTP Unassigned Total
# 55,108 32,162 1,743 10,921 11,003 4,521 7,806 4,407 3 127,674
% 43.16% 25.19% 1.37% 8.55% 8.62% 3.54% 6.11% 3.45% 0.00% 100.0%
Language English Chinese Spanish Other Vietnamese Russian Total
# 64,774 40,398 16,334 2,538 3,070 560 127,674
% 50.73% 31.64% 12.79% 1.99% 2.40% 0.44% 100.0%
Annual Growth
127,674
122,135
72,000 62,000 52,000
SFHP Anthem Blue Cross Total
Market Share* # % 123,351 84.8% 22,085 15.2% 145,436 100.0%
* Source: http://www.dhcs.ca.gov/dataandstats/reports (http://www.dhcs.ca.gov/dataandstats/reports/Documents/MMCD_Enrollment_Reports/MMCEnrollRptJuly2015.pdf)
24
Healthy Workers (HW) Membership Sep-14 Oct-14 Nov-14 12,265 12,192 12,191 Net New 0 -73 -1 % New 0.00% -0.60% -0.01% 11797 11806 11815 Key: = Actual ; ▲ = Goal
Sheet 1 Dec-14 11,876 -315 -2.58% 11824
Jan-15 11,837 -39 -0.33% 11834
Feb-15 11,839 2 0.02% 11843
Mar-15 11,821 -18 -0.15% 11852
Apr-15 11,792 -29 -0.25% 11861
12,400
May-15 11,826 34 0.29% 11871
Jun-15 11,801 -25 -0.21% 11880
Jul-15 11,762 -18 -0.15% 12258
Aug-15 11,718 -44 -0.37% 12256
Aug-15 Aug-14 Change
11,718 12,283 -565
-4.60%
Medical Group SFCCC + DPH Total
# 11,718 11,718
% 100.0% 100.0%
Language Chinese English Russian Other Spanish Vietnamese Unassigned Total
# 5,103 2,642 1,863 1,344 628 138 0 11,718
% 43.5% 22.5% 15.9% 11.5% 5.4% 1.2% 0.0% 100.0%
Annual Growth
12,300 12,265 12,192
12,200
12,191 12258
12256
12,100 12,000 11,900
11,837
11,839
11,876
11,800 11797
11806
11815
11824
11834
11843
11,821 11852
11,826 11871 11,801 11880
11861
11,762 11,718
11,792
11,700 11,600 11,500 11,400
25
Healthy Kids (HK) Membership Net New % New
Sep-14 2,174 -10 -0.46% 2,175
Oct-14 2,178 4 0.18% 2,180
Nov-14 2,166 -12 -0.55% 2,185
Sheet 1 Dec-14 2,122 -44 -2.03% 2,190
Jan-15 2,091 -31 -1.46% 2,250
Feb-15 2,094 3 0.14% 2,250
Mar-15 2,097 3 0.14% 2,250
Apr-15 2,067 -30 -1.43% 2,250
Key: = Actual ; ▲ = Goal
2,300 2,200 2,100 2,000
2,174
2,180
2,178
2,185
2,250
2,250
2,250
2,250
2,250
2,190 2,163
2,162
2,166 2,122
Jun-15 2,036 56 2.83% 2,250
Jul-15 2,037 1 0.05% 2,163
Aug-15 1,996 -41 -2.01% 2,162
Aug-15 Aug-14 Change
1,996 2,171 -175
-8.06%
Medical Group SFCCC + DPH HILL CCHCA NEMS NMS UCSF BTP Unassigned Total
# 1,386 155 110 155 5 89 96 0 1,996
% 69.44% 7.77% 5.51% 7.77% 0.25% 4.46% 4.81% 0.00% 100.00%
Language Spanish Chinese English Vietnamese Other Russian Total
# 1,615 204 148 5 21 3 1,996
% 80.91% 10.22% 7.41% 0.25% 1.05% 0.15% 100.00%
Annual Growth 2,250
2,175
May-15 1,980 -87 -4.21% 2,250
2,091
2,094
2,036
2,097 2,067
1,980
2,037 1,996
1,900 1,800 1,700 1,600 1,500
26
First Name
Last Name
Degree
Company
Address
City
State
Zip
Email
Phone
Kathleen
Liu
Pharm.D.
SFDPH
Castro Valley
CA
94546
[email protected]
(510) 3328212
Shawn
Houghtaling
Pharm.D.
Walgreens Pharmacy
SF
CA
94132
[email protected] m
(650)5204583
Heather
Houska
Pharm.D.
SFDPH
SF
CA
94110
[email protected]
(415) 2062326
Jaime
Ruiz
M.D.
SF
CA
94110
[email protected]
(415) 5523012
Joseph
Pace
M.D.
234 Eddy Street
SF
CA
94102
[email protected]
(415) 3535093
Ron
Ruggiero
RPH
2206 Kenry Way
SF
CA
94080 -5506
[email protected]
(650) 9221118 or (650) 8733257 home
Ted
Li
M.D.
Mission Neighborhoo d Health Center Department of Public Health UCSF Department of Clinical PharmacyRetired NEMS
19531 Barclay Rd. 230 Shields Street 1001 Potrero Ave, 1P2 240 Shotwell Street
SF
CA
94134
[email protected]
Lauren
Goldman
MD
SF
CA
94110
[email protected]
415-3919686 X6142 415-2065452
Roger
Tiao
Pharm.D.
2574 San Bruno Ave 1001 Potrero Ave, UCSF Box 1364, 2409 Camino Ramon PO Box 5080
San Ramo n
Ca
94583
[email protected]
San Francisco General Hospital Hill Physicians
27
925-3276595
Robert (Brad)
Williams
MD
James
Glauber
MD
Steven
Wozniak
MD
Mission Neighborhoo d Health Center SFHP South of Market Mental Health
240 Shotwell Street
San Franci sco
Ca
94110
[email protected]
202 Third St., 7th floor 760 Harrison St.
San Franci sco San Franci sco
CA
94103
[email protected]
CA
94107
[email protected]
28
415-5523870
415 836 1746
HE-02: Initial Health Assessment Updated/Corrected: • Clarifies the methodology of identifying IHAs. • Clarifies the monitoring of IHA completion rates. Pharm-01: Pharmacy & Therapeutics Committee Added: • Adds “Monitoring” section to ensure policy compliance. Deleted: • Removes section on “Exclusions, Limits, and Quotas” and moves them to Pharm-02 (Pharmacy Prior Authorization) and new P&P Pharm-14 (Formulary Exclusions, Limits, and Quotas). Pharm-02: Pharmacy Prior Authorization Added: • Adds procedure for PA approvals. • Adds Therapeutic Interchange policy and moves Step Therapy policy from Pharm-01 (Pharmacy & Therapeutics Committee). Updated/Corrected: • Clarifies role of external review to recommend to SFHP physician or pharmacist for final determination. Deleted: • Deletes procedure on deferrals, which are no longer done. Pharm-10: PGY1 Managed Care Pharmacy Residency Program Added: • Adds procedure on residency evaluation and on successful completion of residency. Pharm-13: After-Hours Pharmacy Access Added: • Adds procedure to evaluate sufficiency of pharmaceutical quantity dispensed upon ER discharge. • Adds provision for processing prescription claims submitted after business hours for prescriptions that require prior authorization. • Adds provisions to Monitoring section to evaluate quantity and day supply for prescription claims associated with an ED visit and the time which prescription claims with an associated ED visit were processed by the pharmacy. QI-06: Member Grievances and Appeals Added: • Adds a procedure for reporting systems grievances. Updated/Corrected: • Clarifies the responsibilities of the Grievance Oversight Committee and Grievance Review Committee. • Clarifies the frequency of meetings of the Grievance Oversight Committee. UM-03: Organ Transplants Updated/Corrected:
29
•
Updated Monitoring section to reflect current practice
Biennial Review: No Other Changes UM-22: Authorization Requests Added: • Add provisions for referral and coordination of care for members when a provider has a moral objection to providing a service. • Links to PR-07 Provider Network Membership Ratios and QI-05 Access Policy & Standards Updated/Corrected: • Clarifies out-of-network provider coverage including seldom used or unusual specialties, and monitoring of out-of-network referrals to determine network adequacy. • Clarifies monitoring and reporting procedures for turnaround times. UM-38: Durable Medical Equipment Added: • Removes reference to CMS/Medicare criteria to evaluate medical necessity for wheelchairs, which is no longer applicable. Deleted: • Removes Medi-Cal definition of “medical necessity.” • Removes financial threshold reference as trigger to DME consultant evaluation. • Removes Oxygen Request Verification Form, which is no longer used. UM-48: Repatriation Updated/Corrected: • Clarifies the procedure for members who refuse repatriation.
30
San Francisco Health Plan Utilization Mangement Committee Tuesday, August 18, 2015 3:30 pm to 5:00pm, Excelsior Conference Rm. Meeting called by:
Collin Elane
Type of meeting:
Monthly Meeting
Attendees:
Glauber, James; McDonald, Kirk; Elane, Collin; Cale, Matija; Donald, Fiona; Hefflefinger, Maika; Tai, Tony; Baldzikowski, Monica; Au, Rebecca; Nguyen, Kendrix Absent: Ratnesar, Dr. Rajendra; Mostovestsky, Olga; Custodio, Ralph;
Topic 1. 2.
3. 4.
5.
6.
7.
8.
Brought By
Recorder: Maika
Time
Discussion
Review: Action items Standing Agenda: Overturned Appeals Review: Decision Log
Collin/All
3:30-3:45
•
Action Items from 07/21/2015
Collin
3:45-4:00
•
Maika
4:00-4:05
• •
Discuss o UM o Rx Recommendations Decisions Log
Update: Coordinator Approvals Review: Specialty Referral Tracking Discuss: Inpatient Admits/1000 Discuss: Exception Auths/SFHN
Tony
4:05-4:15
• •
Go Live Services Impacted
Collin
4:15-4:30
•
Review
Kirk
4:30-4:45
• •
Review Adopt
Collin
4:45-4:55
•
Review: Next Steps/Action Item Review
Collin
4:55
Discuss SFHN notification of UM operational updates o Possible topics: approval of non-covered benefits/services, financial threshold, removal of auth requirements, removal of med nec review Action Items
31
Action
ACTION ITEMS: ITEM # 1.
OWNER
ACTION ITEMS
Collin
•
•
•
• • •
STATUS
(07/21/15) Initiate Meetings for: What level of participation does directors have in this lettering process; Discussion of the level of specificity for NOA Letters; Commission a sub group to build a document of standards for NOA letters with Fiona: IN PROCESS (07/21/15) Add to agenda for next meeting: 1) Discussion on approving a medication in-patient when only to be prescribed as outpatient? Discussion about exclusions to the per-diem. We should have a standard. 2) Notification time frames for ER IN PROCESS (08/18/15) We will continue to look at the coding and to how we are tracking specialty referrals. Work with Monica to pull numbers. Potentially take back a past action item on specialty referral tracking report since not as much work is needed as we had predicted. (08/18/15) Jim and Collin will investigate other resources on what would be a better benchmark for tracking inpatient admits/1000. (08/18/15) Find out if there is any language in the TPA that explicitly states our responsibility to report process changes? (08/18/15) Is it SFHP or SFHN’s risk in making changes to prior auths and how it affects QNXT (08/18/15) Jim and Collin will investigate other resources on what would be a better benchmark for tracking inpatient admits/1000.
2.
Jim
•
3.
Tony
•
For UM Report Card metric “Monitor Provider Appeals TAT” – Tony is finding out about and following up on the appeals turn around metric: COMPLETE
4.
Matija
•
(06/23/2015) Laguna Honda Update on reaching goal on Sept. 1 for rolling this up and letting everyone know that we no longer will be processing prior auth’s for Laguna Honda. COMPLETE on 09/01/2015 (08/15/15) Follow-up with with PBM to address Action Item #2 of Collin’s Action Items above. Review the transgender edits and modifications as a team and vote via email.
• 5.
Everyone
•
st
1. Defining medical director role in NOA process – ongoing. 2. We will need to do more digging on this to make a more valuabe discussion. Matija will follow-up with PBM.
1. Currently only tacking outpatient provider appeals, but we are gong to try to do both inpatient and outpatient going forward. Continued monitoring. 1. We are all set on all action items. The last thing I need to do is let staff know st that we are going live on Sept. 1 .
PARKING LOT: ID# 1.
ITEM
DATE LOGGED
32
STATUS
2. DECISIONS ID#
ITEM We will continue to keep the same level of transparency as we have been in our relationship with SFHN as their TPA.
1. 2.
No PA medical necessity for dialysis and dialysis drugs in-medical group.
DATE LOGGED 08/18/15 08/18/15
Meeting Notes from 08/18/15 Action Item Updates 07/21/15 ITEM #
OWNER
1.
Collin
2.
Patty
3.
Tony
4.
Matija
ACTION ITEMS
STATUS
1. (07/21/15) Define what falls under Radiology and how to operationalize? 2. (07/21/15) Follow-Up with Jose on UM Report Card 3. (07/21/15) Initiate Meetings for: What level of participation does directors have in this lettering process; Discussion of the level of specificity for NOA Letters; Commission a sub group to build a document of standards for NOA letters with Fiona 4. (07/21/15) Add to agenda for next meeting: 1) Discussion on approving a medication in-patient when only to be prescribed as outpatient? Discussion about exclusions to the per-diem. We should have a standard. 2) Notification time frames for ER.
(07/21/15) Patty will follow-up what the next steps are for THS to get a letter. 1. (06/23/2015) PT/OT/ST approval at UM Coordinator Level and monitoring report 2. For UM Report Card metric “Monitor Provider Appeals TAT” – Tony is finding out about and following up on the appeals turn around metric
st
(06/23/2015) Laguna Honda Update on reaching goal on Sept. 1 for rolling this up and letting everyone know that we no longer will be processing prior auth’s for Laguna Honda.
up with Olga Overturned Appeals
33
1.
Moving forward with InterQUal without imaging; not requiring medical necessity for radiology services 2. Happy with the decision we made last time at UM. Report cards will me more meaningful in the future. 3. Defining medical director role in NOA process – ongoing. 4. We will need to do more digging on this to make a more valuabe discussion. Matija will follow-up with PBM. This is fully operational. When we get releases, we will be ready to share. 1. This is operational; there is only one grievance and NOA letter that was sent. No other problems. 2. Currently only tacking outpatient provider appeals, but we are gong to try to do both inpatient and outpatient going forward. Continued monitoring. We are all set on all action items. The last thing I need to do is let staff know that we are going st live on Sept. 1 .
No UM overturned appeals from Nicole. Harvoni – Denied due to lack of medical necessity and overturned – there were a few cases that have appeared in our Px overturned appeals and there seems to be a pattern. Is this a criteria that we want to dicuss? Fiona says, “Yes.” Documentation on patient compliance is being provided now (which it was not in the past) on the appeal. Kendrix says we are giving a thorough documentation of why these cases are being denied. For certain clincs like SFGH, even though may not include this information in the paperwork, we do know their process and assume given our knowledge. Fiona says we are happy with the current process and that we should coninute to monitor throughout the year. Waiting to hear back from the state on the current status of the rebate. None right now. MS Cotin – denied by Dr. Donald due to a non-formulary medicine not being covered unless preferred medicines having been used. There was a policy change – we no longer require this anymore – overturned. Decisions Log A UM Committee Decision Log has been created in SharePoint that documents every decision voted and agreed on in each UM Committee Meeting. The log is organized by date and is layed out in a very simple format. There could be means for improvement in the future – categorizing decisions, etc. Coordinator Approval This will start 9/1 for medical supplies – incontinent, cPAP – the lists have been vetted through Monica, Matija, and Patty. Included in this is year-long units and authroizations. We will have very in-sync lists of supplies; by creating these lists we have been able to reduce any confusion on what items have a year-long authorization. This was rolled out to the nurses today Specialty Referral Tracking We have a requirement by DHCS to track all referrals that are approved – to show that these have happened or not. We reconciled this with all referrals that we approved and made sure it was attached to a claim. If it’s not attached to a claim, then this referral does not exist and we need to complete this form. Last quarter we’ve had over 100 members, and this quarter there is only 10 members that have had a referral and no claims attached. What really cut this list down is the number of claims attached so one thing we can think about, regarding if this count is wrong, is if claims were attached erroneously. We will continue to look at the coding and to how we are tracking specialty referrals. Collin will work with Monica to pull these numbers. Potentially take back a past action item on specialty referral tracking report since not as much work is needed as we had predicted. Inpatient Admits/1000 Inpatient Admissions per 1000 – National: 106.3 (yr. 2013 American Hospital Association); California State/Local: 13, Nonprofit: 59, For-profit: 13 = total 85 (yr. 2013 – Kaiser Family Foundation); California Rank 42: 86.3 admision rate (yr. 2012 - Appraise Health Insight) Our exisiting bench marks for DHCS, NCQA, or HEDIS does not capture this data, unfortunately. DHCS does require, however, that we track this. What about our fellow plans? Collin says they ask us for benchmarks. Perhaps we can get these bench marks from another sister plan, although unlikely, Jim says. Kirk mentions that we can partner with a data analysis consultant as another route.
34
We could maybe start looking at our DRG’s for our non-contracts financially, since currently SFHP is paying out a lot. We could do better on our bed days in terms of management and how to keep people away from non-contracted facilities. There are possibly 5 to 10 people/day that go to non-contracted facilities. This is just a suggestion for another report for analysis. Jim and Collin investigating other resources on what would be a better benchmark for tracking inpatient admits/1000. Exception Auths/SFHN What is the legacy information behind this because we hyave been using this model for UM to perform and report on for years? Do we need to improvel our level of transparency to SFHN? Number of approved non-covered codes were much higher in the past, so in the past we were approving way more of those than we are now. In the past, we have never told SFHN about the exclusions. Examples that may need better transparency is pulmonary rehabs resources and Monica says that she has no idea what those thresholds would be and how much pulmonary rehabs cost. Fiona says though that a threshold may not be a bad idea, given that we may not be wrongly allocating resources to pulmonary rehabs rather than out of network cases. Fiona – Question that needs to be answered: Is there any language in the TPA that explicitly states our respobibility to report process changes? (Collin) Other things that we are looking at are cardiac rehab, genetic screening, etc. If the contract language is saying that they are giving us authority given our solicited information, there could be cases that pulmonary rehab could be a benefit. As long as we are acting as their fudiciary in good faith. Collin says we will revisit in the future if anything changes. Decision: We will continue to keep the same level of transparency as we have been in our relationship with SFHN as their TPA. Transgender Edits Fiona’s last action items was to modify criteria based on three things that came up: 1) All surgical requests have documentation of mental health evaluation. 2) We would require a less frequent documentation schedule leading up to surgery. This has been changed to within 3 months of surgery scheduled date. 3) Hair removal procedures; SFHP will cover this benefit when criteria are met. If we have a provider that has an established track record, documentation for patient education is not needed. SFHP will cover electrolysis and laser hair removal in conjeuction with the following procedures… Action item for everyone: Review these transgender edits and modifications as a team and vote via email. Action item: Is it SFHP or SFHN’s risk in making changes to prior auths and how it affects QNXT? If a code has been out of the excluded bucket vs. not. (Collin) Dialysis Documentation – make a decision to streamline PDR’s Ideally, SFHP will not require prior auths for dialysis in medical group at UCSF including DaVita, and REI. Monica suggests that we document that we don’t require a prior auth for dialysis and dialysis drugs in medical group, at least for medical necessity review. This in turn, can go to the coordinator level and take this work load off the nurses. This confirguaration in the system would take many months, and I don’t think it makes sense for Tanya to have to review these over the next months until it gets reconfigured in the system.
35
Are there any risks? It would be a vendor fraud risk, and we haven’t looked at this data since project 1. It’s an issue of trusting our network. I don’t know of anyone in the network that is looking at trending for contracted vendors DaVita and REI (and DME’s). Historically, PA’s reposibility was to keep this in track. Decision: No PA medical necessity for dialysis and dialysis drugs in medical group.
36
San Francisco Health Plan Utilization Mangement Committee Tuesday, September 15, 2015 3:30 pm to 5:00pm, Excelsior Conference Rm. Meeting called by:
Collin Elane
Type of meeting:
Monthly Meeting
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 1. 2.
3.
4.
5.
Review: Action items Standing Agenda: Overturned Appeals Review: Q2 Pharmacy Utilization Review Decision: Updated UMC Charter Review: Reports Review Schedule
Brought By
Recorder: Maika
Time
Discussion
Collin/All
3:30-3:45
•
Collin
3:45-4:00
•
Jim
4:00-4:10
Collin/Kirk
4:10-4:20
• •
Draft Charter Added “no unduly financial influence” language
Kirk/Collin
4:20-4:40
• •
Reports schedule Development of catalogue o Exact report name o Links o Exact review dates How do we review? (example: leadership reviews with analysis and recommendations and then present in UMC? Part of consent agenda ? Others?) DMG related reviews? DHCS next steps o Quality Audits o MD documentation
Discuss o UM o Rx • Recommendations PerformRx Slides
•
6.
Update: DHCS CAP New
Collin
4:40-4:55
Action Items from 07/21/2015
• •
37
Action
Topic
Brought By
Time
Development
7.
Review: Next Steps/Action Item Review
Maika
4:55
Discussion
Action
o DCP o Coordination of care o PCP/Spc Referral (PA and CCR) Action Items
ACTION ITEMS: ITEM #
OWNER
ACTION ITEMS
STATUS
1.
Collin
2.
Jim
1. (09/15/15) Needs to discuss with Matija on how we can flag SFHN vs. Consortium in Essette, in relation to single-point-of-contact in discharge planning. 2. Work with Maika to look back on 7/21/15 minutes for ER notification time frames and report back to Matija if there are any action items. 3. (08/18/15) Jim and Collin will investigate other resources on what would be a better benchmark for tracking inpatient admits/1000. Ongoing 4. (08/18/15) Find out if there is any language in the TPA that explicitly states our responsibility to report process changes? TPA under review, but no specific language 5. (08/18/15) Is it SFHP or SFHN’s risk in making changes to prior auths and how it affects QNXT Ongoing discussion 1. (08/18/15) Jim and Collin will investigate other resources on what would be a better benchmark for tracking inpatient admits/1000. Ongoing
3. 4.
Ralph Matija
1. (09/15/15) Follow-up to ensure that our medical groups are using the new APL. 2. (09/15/15) Needs to discuss with Collin on how we can flag SFHN vs. Consortium in Essette, in relation to single-point-of-contact in discharge planning. 3. (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 onsie and twosies.
5.
Fiona
6.
Kendrix
1. (09/15/15) Finalize Transgender criteria edits. Changes were regarding logistical issue of documentation within 3 months of surgery. Fiona will send edits out and if she doesn’t hear any concerns by this Friday, 9/18/15, the decision to keep these edits will have been made. 1. Review the criteria again for Dronabinol to see if we can broaden our terms. 2. NOA language modification.
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PARKING LOT: ID# 1.
ITEM
DATE LOGGED
STATUS
2. DECISIONS ID# 1.
ITEM
DATE LOGGED
2.
Meeting Notes from 09/15/15 Past Action Items Follow-Up ITEM # 1.
OWNER
ACTION ITEMS
STATUS
Collin
•
(08/18/15) Jim and Collin will investigate other resources on what would be a better benchmark for tracking inpatient admits/1000. Ongoing (08/18/15) Find out if there is any language in the TPA that explicitly states our responsibility to report process changes? TPA under review, but no specific language (08/18/15) Is it SFHP or SFHN’s risk in making changes to prior auths and how it affects QNXT Ongoing discussion (08/18/15) Jim and Collin will investigate other resources on what would be a better benchmark for tracking inpatient admits/1000. Ongoing
- Ongoing - We will not provide additional information unless asked. - Ongoing Discussion
For UM Report Card metric “Monitor Provider Appeals TAT” – Tony is finding out about and following up on the appeals turn around metric: COMPLETE (08/15/15) Follow-up with with PBM to address Action Item #2 of Collin’s Action Items above. o (07/21/15) Add to agenda for next meeting: 1) Discussion on approving a medication in-patient when only to be prescribed as outpatient? Discussion about exclusions to the per-diem. We should have a standard. 2) Notification time frames for ER.
Complete!
• • 2.
Jim
•
3.
Tony
•
4.
Matija
•
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Ongoing
Matija met with contracts and Rx – all medication should be included in the per diem; Rx out patient management is paid from SFHP funds - Finance does not audit PBM; our consulting firm PerformRx does this. - We need to continue to dig up and then figure out how much effort we want to do this. We are more concerned with the onsie and twosies and how much effort we want to put in to pursue this. - Notification time frames for ER (Maika)
5.
Everyone
•
Review the transgender edits and modifications as a team and vote via email.
Overturned Appeals One for Medical and three for Pharmacy Medical Power wheel chair – NEMS case that was overturned based on the new APL; Donald claimed that it was medically necessary. No action items here except to continue to use the new APL. Is this a mandated guideline that is regulated by the state or can we use InterQual? Ralph’s Action Item – Follow-up to ensure that our medical groups are using the new APL. Pharmacy 1) Hill Patient Case regarding Obsumit - Our criteria recommends that a patient to tries Ambrisentan first. Additional information provided and the patient was found to have peripheral endema and therefore this appeal was overturned. Are we able to defer? If a patient can’t use Ambrisentan first, the only thing provider needs to do is submit some documentation claiming why. Use modification correctly for the NOA. If there is an alternative medication, this is a denial. 2) Harvoni – at the time, patient met medical necessity criteria but was missing some documentation. Criteria requires meeting a specific APRI score range that the patient had met. 3) Dronoabinol – medication will only be appoved for HIV-related anorecia and cachecia and chemotherapy induced nausea and vomiting; patient was originally denied since this medication is not FDA-approved for patient’s condition. Due to patient trying other alternative medications which proved not effective, this appeal was overturned. Kendrix’s Action Item - We may want to review the criteria again for Dronabinol to see if we can broaden our terms. Review and modify NOA language. Yearly Pharmacy Utilization Review Review of our costs and utilization for pharmaceuticals and therapy. This presenation compares last year to the year before. Number of prescription for members per month – 10% decline since the FY 13-14. 13% decrease in utilization by Medicare/Medical population. This is consistent with what federal acutaries are predicting given Medi-Cal expansion. Generic utilizations have stayed relatively the same. 30-day supply of non-specialty medication increased by 21%. 16% increase for specialty medications due to the introduction of Harvoni.
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Overall specialty vs. non specialty – 24% higher on per member/month basis. For PMPM Non-Specialty – static on the nonspecialty side (50% trend) with little increase over the last year. 7.5% prince inflation; 2.5% utilization; 8.6% total trend. Benchmark comparisons – Avg. Cost Per Rx, Generic Dispensing Rate, Plan Paid PMPM, etc. – Nothing too much to harp on. Top 25 Costly Medications: o Harvoni, Sovaldi, Humira, Viread (we no longer pay for anymore; for HIV and Hep B; what’s carved out for one indication is carved out for the other); Asthma and Diabetes are our top two chronic conditions that we have created our disease management programs for (the costs for these medications combined are rivaling the cost of Harvoni). o Top 25 Drugs take up 35% of out total costs. Opiates in the previous year 33,000 and this year 48,000 (Rx Count) – if you look at it at a member/month basis in the context of our increased enrollment, this data actually show a decreased rate in opioid utilization. Decision: Review PerformRx audit report every year. Updated UMC Charter Edited the No Finanical Incentives Regarding UM Decisions: There are no financial incentives given to UMC members that are qualified to perform utilization review services for SFHP; they are salaried employees of SFHP. Decision: Approved edit for No Finanical Incentives Regarding UM Decisions. Reports Review Schedule Kirk has compiled a list of collaterals that at some frequency needs to be reviewed with some type of committee or board. We have this meeting today at DENOC. We are recommending that the delegated review is completed at DENOC and the DENOC’s analysis is passed on to UMC for us to review at meetings and vote on. Existing list of collaterlas include program descriptions, file reviews, specialy referral tracking, denial log, and work plan – some of which are quarterly, bi-annually, or annually. The workplan consists of multiple acitvites and there is a lot there. Within SFHP, we have a report card and review in Clinical Ops; there areother things to review for NCQA and DHCS (Committee minutes, policies and procedures). Based on actual CAPS, we have a number of these items to review. How many attendees for UM sub-committee currently participate at DENOC, specifically clinical representatives? We will need some clinical representation so clinical folks in UM Committee will need to assist at DENOC. Some of these CAP items will require multiple reports. We will need to create a log/schedule on which of these reports and items we will review and vote on at each meeting for the next year. Do we need to look a turn-around reports? Yes, we will need to consider this.
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Decision: We will continue the sub-committee for DENOC and do an in-person collateral review with recommendations. Topics and content reviewed ad-hoc and analysis will be brought to UM Committee.
DHCS CAP New Development There are 5 new, major initiatives that will try to work on and implement by the end of this year (e.g. quality audits of denial files). We do a yearly IRR. At Alameda, Donna used Milliman and had an IRR, but that isn’t sufficient for SFHP so we do it through InterQual. In addition to the denials, some of the modified ones. Physician documentation was related to the CAP finding that some of our physicians were not documenting that a medical director review occured. We need to build this into our system. Discharge Planning wasn’t an actual finding but since it has a lot of visibility, we want to make sure that it has an evolving role for our concurrent review team. Are we veering away from IP-IP repatriation? Collin thinks that it will be more coordination with CCS/DGRC Coordination of Care that now Donna is going to inherit. Is there something in that report that will state readmissions? The QIC workplan includes all-cause readmissions and since it’s been completed it’s going to be rolled into operations. All-cause readmissions will be one of the metrics that we will be using here. Jessica Warren will be meeting with Donna and Collin to review. PCP and Specialty Referral – callout to repurposing of SFHN for discharge planning; we will have single-point-of-contact to make appointments for PCPs and Specialty’s. Collin and Matija’s Action Item - Needs to discuss how we can flag SFHN vs. Consortium in Essette, in relation to signle-point-of-contact in discharge planning. Action Items 1. Ralph’s Action Item – Follow-up to ensure that our medical groups are using the new APL. 2. Kendrix’s Action Item – Review the criteria again for Dronabinol to see if we can broaden our terms. NOA language modification. 3. Collin and Matija’s Action Item - Needs to discuss how we can flag SFHN vs. Consortium in Essette, in relation to single-point-of-contact in discharge planning. 4. Fiona’s Action Item - Finalize Transgender criteria edits. Changes were regarding logistical issue of documentation within 3 months of surgery. Fiona will send edits out and if she doesn’t hear any concerns by this Friday, 9/18/15, the decision to keep these edits will have been made. 5. Maika and Collin’s Action Item – Look back on 7/21/15 minutes for Notification time frames and report back to Matija if there are any action items. Decisions 1. Review PerformRx audit report every year. 2. Approved edit for No Finanical Incentives Regarding UM Decisions. 3. We will continue the sub-committee for DENOC and do an in-person collateral review with recommendations. Topics and content reviewed ad-hoc and analysis will be brought to UM Committee.
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Pharm-14: Formulary Exclusions, Limits, and Quotas New Policy (Please see P&P) Outlines SFHP’s policy and procedure on pharmacy formulary exclusions, limits, and quotas, including for: o Brand medications o Drug utilization review (DUR) edits o Medi-Cal formulary exclusions o Day supply o Diabetic supplies o Respiratory supplies o Blood pressure monitors QI-05 Timely Access Regulations Additions: • • • • • •
More specificity as to the standards References the Access to Care Committee for monitoring of standards More specificity regarding the PAAS survey methodology Moved definition of triage and screening to the definitions section Identifies clear data sources Procedures for after-hours survey, provider satisfaction, provider time to answer, Health Plan CAHPS
Removed: • • • • • • •
Advanced access information deemed unnecessary as advanced access will be shown through the PAAS survey and is held to the same appointment availability standards Hours of operations information Definition of 24hour access (used in Nurse Help Line) Procedures for unusual specialty services Procedures for seeking care which your provider has a moral objection Mention of Healthy Families Monitoring CHN differently than others
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SFHP POLICY AND PROCEDURE Monitoring Accessibility of Provider Services Policy and Procedure number: Department Owner: Lines of Business Affected:
QI-05 Health Improvement Medi-Cal, Healthy Workers, Healthy Kids POLICY STATEMENT
SFHP annually assess the provider network’s compliance with the accessibility standards set forth in Table A through various surveys described in the procedures section of this policy. Any findings of noncompliance are brought to the Access to Care Committee for review and investigation; see Policy QI-13 for more information. Table A. SFHP’s accessibility standards Data Source Provider Appointment Availability Survey
Topic
Standard
Wait times in provider offices
Wait time not to exceed 30 minutes
Provider Time to Answer Calls
Wait time not to exceed 10 minutes during business hours
Provider Time to Answer Survey
Triage and screening, answering services, and after-hours access at provider sites
Providers maintain 24/7 triage or screening services by telephone. Phone wait time does not exceed 30 minutes. *
Provider After-Hours Survey
Access to non-urgent primary care appointments
Non-urgent appointments offered within 10 business day of request †‡
Initial prenatal care appointment
Initial prenatal care appointment offered within two weeks (14 calendar days) Within 15 business days of request †‡
Provider Appointment Availability Survey, CAHPS access composite, Provider Satisfaction Survey Provider Appointment Availability Survey
Access to non-urgent specialty appointments Access to urgent appointments that do not require prior authorization Access to urgent appointments that require prior authorization
Within 48 hours of the request for an appointment †
Provider Appointment Availability Survey, CAHPS Access Composite, Provider Satisfaction Survey Provider Appointment Availability Survey
Within 96 hours of the request for an appointment †
Provider Appointment Availability Survey
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Access to non-urgent mental health physician appointment
Within 15 business days of the request for an appointment †‡
Provider Appointment Availability Survey
Access to non-urgent appointments with nonphysician mental health providers Access to non-urgent appointments for ancillary appointments for the diagnosis of injury, illness, or other health condition Triage and screening, answering services, and after-hours access through the plan
Within 10 business days of the request for an appointment †‡
Provider Appointment Availability Survey
Within 15 business days of the request for an appointment †‡
Provider Appointment Availability Survey
Health Plan maintain access to 24/7 triage or screening services by telephone. Phone wait time does not exceed 30 minutes.
Nurse Help Line Report
Enrollee Satisfaction Survey
NCQA Medicaid 25 Percentile for composites “Getting Care Quickly” and “Getting Needed Care”
HP-CAHPS Survey
Provider Satisfaction Survey
No statistically significant decrease in provider satisfaction in timely access composite compared to previous year
Provider Satisfaction Survey
th
* Providers that provide telephone triage or screening services must have a telephone answering machine, answering service, and/or office staff that will inform the caller about: (1) the length of wait for a return call from the provider and (2) how the caller may obtain urgent or emergency care. If providers cannot provide triage or screening services within 30 minutes, members may access SFHP’s Nurse Help Line. Unlicensed staff persons handling member calls may ask questions on behalf of a licensed staff person in order to help ascertain the member’s condition so that appropriate referral to a licensed staff can be made. † Exception 1: The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the enrollee. ‡ Exception 2: Preventive care services and periodic follow up care may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of his or her practice.
PROCEDURES I. Compliance with Access Standards SFHP uses the following procedures for monitor compliance with the standards in Table A. A. Provider Appointment Availability Survey (PAAS) SFHP monitors compliance with urgent and non-urgent primary and specialty care (with and without prior authorization), initial prenatal care, non-specialty mental health (for medical and non-medical providers), 2
46
and non-urgent ancillary appointment standards through the survey methodology distributed by the Department of Managed Health Care (DMHC). SFHP monitors, at minimum, select types of specialists and ancillary providers identified through the annual DMHC methodology. Additionally, PAAS monitors wait time in providers’ offices, noting time from member arrival until roomed. SFHP participates in The Industry Collaborative Effort (ICE), which administers the Provider Appointment Availability Survey. In cases where this function is delegated to a Knox-Keene Health Plan, the health plan requires delegates to monitor appointment availability through a survey or other DMHC-approved methodology; results are to be shared with SFHP annually. SFHP reviews results annually for all provider groups through the Access to Care Committee against the standards set forth below: Measure Initial Prenatal Care Appointment Availability Wait Time* Primary Care Provider Appointment Availability Wait Time (Urgent and Non-Urgent)* Specialty Care Provider Appointment Availability Wait Time (Urgent and Non-Urgent)*
SFHP Standard 80% of providers surveyed within the network and within the medical groups are within the standard 80% of providers surveyed within the network and within the medical groups are within the standard 80% of each type of specialty provider surveyed within the network and within the medical groups are within the standard 80% of providers surveyed within the network and within the medical groups are within the standard 80% of providers surveyed are within the standard
Ancillary Services Provider Appointment Availability Wait Time (Urgent and Non-Urgent)* Non-Specialty Mental Health Non-Physician Wait Times
*SFHP may request data from the provider group demonstrating that members’ referring or treating physician documented that a wait time longer than the applicable time-elapsed standard would not have a detrimental impact on the health of the member and/or is appropriate for the nature of their condition. B. Nurse Help Line SFHP provides telephone screening and triage services to members through a contracted nurse help line (NHL). The NHL allows members to access screening or triage services 24 hours a day, 365 days a week with wait times not to exceed 30 minutes. SFHP informs members of this service by providing the NHL telephone number on the member ID card. The NHL maintains standard protocols and guidelines for processing calls from members that include the following: • • • • •
A licensed physician or mid-level provider working under the supervision of the physician is available for contact after-hours, either in person or via telephone. Determination of when the call warrants immediate consultation with the on-call supervisor and determination of when the call warrants immediate consultation with the NHL Nurse Determination of when the patient should be instructed to go to the emergency room Notification of emergency medical services (911) for emergency situations Mechanism for access to telephone interpreters
The NHL performance goal is 80% of calls are answered within the 30-minute standard. The Access to Care Committee reviews NHL reports quarterly. C. Health Plan Consumer Assessment of Healthcare Providers and Systems (CAHPS) SFHP uses data from CAHPS patient satisfaction results to identify potential access issues and areas for improvement. CAHPS questions regarding accessibility of services within SFHP’s network include routine appointment access, urgent access, specialty access, as well as wait times in provider offices. th
The CAHPS performance goal is set at the NCQA Medicaid 25 percentile. The CAHPS data and a comparison with the prior year’s survey are reviewed annually by the Access to Care Committee.
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D. Provider Satisfaction Survey SFHP monitors providers’ satisfaction with member access to SFHP’s network through the annual Provider Satisfaction Survey. The questions for providers are, at a minimum, similar to those in the ICE Provider Satisfaction Survey tool. In cases where the function is delegated, health plans are required to use the ICE Provider Satisfaction Survey questions or similar questions. The survey is conducted on an annual basis to physician and non-physician mental health providers. The performance goal for provider satisfaction with access to services has no statistically significant decrease in satisfaction in comparison to the previous year’s performance. The results from the survey and a comparison with the prior year’s survey will be reviewed annually by the Access to Care Committee. E. Provider Time to Answer Survey SFHP surveys provider offices’ time to answer telephone calls on an annual basis. SFHP will call a random sample of providers within each medical group, monitoring both the time to answer and the time to return the telephone call. SFHP will survey a random sample of no less than 20 providers. The survey performance goal is 80% of providers in each medical group must answer within 10 minutes. Results are reviewed at the Access to Care Committee annually. F. Provider After-Hours Survey Methodology SFHP monitors providers’ compliance with after-hours telephone triage or screening services through participation with the Provider After-Hours survey, which is administered by the Industry Collaborative Effort (ICE). The Provider After-Hours survey measures after-hour access to primary and behavioral health providers by assessing availability of triage services by an appropriate licensed professional, as well as wait time for such triage services. SFHP reviews results annually for all provider groups through the Access to Care Committee against the standards set forth below: Measure 24/7 availability of screening or triage services by an appropriately licensed professional Telephone wait time not to exceed 30 minutes
Standard 80% of providers surveyed within the network and within the medical groups are within the standard 80% of providers surveyed within the network and within the medical groups are within the standard
G. Annual Timely Access Report SFHP compiles the annual Timely Access Report regarding compliance with the timely access timeelapsed standards set forth in 28 CCR §1300.67.2.2. The Annual Timely Access Report, which consists of a Compliance Report and Provider Network Reports, is submitted to the Department of Managed st Health Care (DMHC) every year on or before March 31 , representing the prior year’s performance. The Timely Access Compliance Report includes the following data as required by 28 CCR §1300.67.2.2(g): 1. Annual provider rates of compliance with the time-elapsed standards. Annual rates of compliance are calculated using the DMHC Provider Appointment Availability Survey methodology and results. 2. Incidents of non-compliance with the Timely Access Regulation resulting in substantial harm to a member, which are identified by any of SFHP’s Committees and/or monitoring activities. The report will include a description of SFHP’s responsive investigation, determination and corrective action. 3. Patterns of non-compliance with the Timely Access Regulation, which are identified by any of SFHP’s Committees or monitoring activities. The report will include a description of SFHP’s responsive investigation, determination and corrective action. 4. If Advanced Access programs are monitored by SFHP during a given measurement year, a list of providers who use an Advanced Access program to confirm that appointments are scheduled
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5. A description of the implementation and use by SFHP and its contracting providers of triage, telemedicine, and/or health I.T. services to provide timely access to care, if any. 6. Provider satisfaction survey results with a discussion of how the current year’s survey results compare with results from the prior year’s survey. 7. Enrollee satisfaction survey results with a discussion of how the current year’s survey results compare with results from the prior year’s survey.
MONITORING The Access to Care Committee reviews the standards and procedures in QI-05 at least annually and asneeded to ensure compliance with current regulatory and contractual requirements.
DEFINITIONS Accessibility: The extent to which a patient can obtain available services at the time they are needed in a physically, culturally and linguistically appropriate manner. Accessibility of providers is ensured by monitoring mechanisms such service refers to both telephone access and ease of scheduling an appointment if applicable. Advanced Access: The provision, by an individual provider, or by the medical group or independent practice association to which an enrollee is assigned, of appointments with a primary care physician, or other qualified primary care provider such as a nurse practitioner or physician’s assistant, within the same or next business day from the time an appointment is requested, and advance scheduling of appointments at a later date if the enrollee prefers not to accept the appointment offered within the same or next business day. Availability: The extent to which a patient can obtain certain services through a health plan’s provider network. Availability of providers is ensured by a provider network that has sufficient numbers and types of practitioners who provide basic health care services. Appointment waiting time: The time from the initial request for health care services by an enrollee or the enrollee’s treating provider to the earliest date offered for the appointment for services inclusive of time for obtaining authorization from the plan or completing any other condition or requirement of the plan or its contracting providers. Triage or screening: The assessment of an enrollee’s health concerns and symptoms via communication, with a physician, registered nurse, or other qualified health professional acting within his or her scope of practice and who is trained to screen or triage an enrollee who may need care, for the purpose of determining the urgency of the enrollee’s need for care. Triage or screening waiting time: The time waiting to speak by telephone with a physician, registered nurse, or other qualified health professional acting within his or her scope of practice and who is trained to screen or triage an enrollee who may need care. Urgent care: Health care for a condition which requires prompt attention. Routine primary care: Preventive or primary care for non-urgent conditions. CAHPS: Consumer Assessment of Healthcare Providers and Systems is a member satisfaction survey developed by the Agency for Healthcare Research and Quality. The survey is administered to Medi-Cal members every other year.
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AFFECTED DEPARTMENTS/PARTIES Clinical Operations Compliance & Regulatory Affairs Marketing Practice Improvement Provider Network Operations
RELATED POLICIES AND PROCEDURES AND OTHER RELATED DOCUMENTS PR-07 Provider Network Composition and Capacity QI-13 Access to Care Committee QI-06 Member Grievance and Appeal Policy & Procedure
REVISION HISTORY Effective Date: Approval Date: Revision Date(s):
June 20, 2011 6/23/2009, 7/9/2009, 9/24/2010, 06/20/2011 June 12, 2009 – policy revision in response to DMHC/DHCS Joint Audit CAP Req. 2.3.1 July 28, 2009 – new policy in response to DHCS contract deliverables 9A, 9B May 19, 2011—policy revision in response to SPD expansion July 10, 2013 – bi-annual review July 16, 2014 September 18, 2015
REFERENCES DHCS Contract Knox Keene Act, Health & Safety Code §§1340-1399.818 California Code of Regulations, Title 28, §§1300.51(d)(H-I), 1300.67.2, 1300.67.2.1, 1300.67.2.2
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SFHP POLICY AND PROCEDURE Formulary Exclusions, Limits, and Quotas Policy and Procedure Pharm-14 number: Department Owner: Pharmacy Services Lines of Business Affected: Medi-Cal, Healthy Kids POLICY STATEMENT San Francisco Health Plan (SFHP) uses exclusions, limits, and quotas in order to determine formulary and prior authorization criteria, and treatment algorithms. PROCEDURE EXCLUSIONS, LIMITS, AND QUOTAS used to determine formulary and prior authorization criteria and treatment algorithms include, but are not limited to: 1. Brand Medication Policy a. SFHP has a mandatory generic policy and requires generic substitution when an equivalent AB-rated generic product is available. Dispensing of brand name medications when generic equivalent is available will be allowed only in the following cases: Pharmacy bills brand medication as DAW 5 (i.e. billed as a generic product). Pharmacy bills brand medication as DAW 8 (i.e. generic formulation is not currently available). Pharmacy is dispensing one of the following narrow therapeutic index drugs: Armour Thyroid, Coumadin, Dilantin, Synthroid. For all other brand name medication requests, prior authorization with documentation of trial and failure of 2 generic medications from different manufacturers will be required. All brand name medication prior authorization requests will be reviewed by an SFHP pharmacist or Medical Director. 2. Drug Utilization Review (DUR) Edits a. Standard DUR edits applicable to SFHP formularies include: medication quantity and age limitations.
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b. All DUR edits are based on FDA approved indications, standards of practice, safety and abuse potential considerations. 3. Medi-Cal Formulary Exclusions a. The following drugs classes are excluded from the SFHP Medi-Cal formulary and are covered by fee-for-service Medi-Cal. TAR may need to be submitted to fee-for-service Medi-Cal for certain medications. Anti-psychotics AIDs/HIV drugs (except didanosine, zidovudine; covered on SFHP Medi-Cal formulary) Alcohol, heroin detoxification and dependency treatment drugs Erectile dysfunction (ED) drugs when used for the treatment of ED Coagulation factors b. Medications in the following categories are excluded from the SFHP Medi-Cal formulary: Fertility agents Drugs for cosmetic indication (e.g. hydroquinone for hyperpigmentation of the skin) 4. Day Supply Policy a. SFHP’s standard day supply policy is 30 day supply for brand and 90 day supply for generic medications. b. Exceptions to the 90 day supply policy for generic medications are as follows: 30 day supply only is allowed for all opiate medications except tramadol. c. Exceptions to the 30 day supply policy for brand medications are as follows: 90 day supply is allowed for all insulin products. Up to 100 day supply is allowed for test strips and lancets. Up to 90 day supply for brand contraceptives AFTER a 30 day trial on the brand medication. Prior authorization request must be submitted explaining the need for 90 day supply of brand medication and documenting that one-month trial has been completed and no side effects were experienced. 5. Diabetic Supplies (applicable for Medi-Cal, Healthy Kids, and Healthy San Francisco formularies) a. The following diabetic supplies are covered: Glucometers: ACCU-CHEK Nano SmartView and ACCU-CHEK Aviva Plus, Accu-Chek Designer Care Kit, 1 glucometer per 365 days. Test strips: ACCU-CHEK SmartView (for Nano) and ACCU-CHEK Aviva Plus test strips with the following quantity limits:
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400 per 100 days for all members 800 per 100 days for members with gestational diabetes Lancets: ACCU-CHEK FastClix, Multiclix, SoftClix lancets, 100 day supply
6. Respiratory Supplies (applicable for Medi-Cal, Healthy Kids, Healthy San Francisco, and Medicare/Medi-Cal formularies) a. The following respiratory supplies are covered for members under 19 years of age with quantity limit of #2 per 365 days: Inhalers and inhaler assist devices Nebulizers Peak flow meters 7. Blood Pressure Monitors (applicable for Medi-Cal and Medicare/Medi-Cal formularies) a. Blood pressure monitors with a value up to $50 will be covered through pharmacy benefits with quantity limit of 1 monitor per member every 5 years. MONITORING A. Aggregate utilization data is subject to retrospective analysis by SFHP’s Clinical Operations Department to evaluate over- and under-utilization of services. B. SFHP evaluates member and provider grievances, appeals, and SFHP’s member and provider satisfaction survey responses to identify patters and determine need for modifications. C. SFHP reviews Managed Care Medi-Cal Noncapitated and Carve-out Drug List from DHCS, when it is available, and make updates accordingly. D. Exclusions, limits and quotas are presented and reviewed by SFHP P&T Committee for all formulary modifications. DEFINITIONS None AFFECTED DEPARTMENTS/PARTIES Health Improvement Pharmacy Benefit Manager RELATED POLICIES AND PROCEDURES, DESKTOP PROCESS and PROCESS MAPS Pharm-01 Pharmacy and Therapeutics Committee Pharm-02 Pharmacy Prior Authorization
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REVISION HISTORY Effective Date: Approval Date: Revision Date(s): REFERENCES NCQA Standard UM 13 Procedures for Pharmaceutical Management
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Quality of Service and Access To Care
Clinical Quality and Patient Safety
Measure A.
B.
Goal
Benchmark/Target
Initial Health Assessment Rate
Improve member engagement with primary care by improving 35% in 2014 the IHA rate by at least 5 percentage points
Medication Therapy Management
Implementation of MTM program one provider group and performance guarantee in place for 1:1 ROI on drug cost savings interventions
Member Grievances and Appeals
Resolve 100% of grievances within 30 days
100% in 2013
B.
PIP Block Funding (improve at least one outcome measure)
66% of PIP Block Funding Participants that demonstrate improvement in at least one measure
No baseline
C.
D.
Specialty Care Third Next Available (TNAA)
Provider Satisfaction
Improve TNNA in 3 specialty clinics by 5 days
SFHP's Rate 38%
Overall ROI $1.69:$1 Level 2 ROI $0.08:$1
NA in 2014
A.
Q3 Results
Comments Data pulled for members effective Q1 2015. Threshold to change for 2016.
We are terming the program effective 10/31. Patient refusal rate in Q3 decreased to 39%.
5 grievances were not resolved within 30 days. The implementation of a weekly grievance committee in 2015 has 97% of grievances were resulted in a resolved in 30 calendar comprehensive review. days As a result, additional investigation, and in two cases, translation requirements, required for the 5 grievances resulted in a slight delay.
Baseline TNAA: Gen Surgery=100 ENT=58 GI=31
62.50%
Not all data reported yet. Expected to meet target by end of year.
Current TNAA: Gen Surgery=55 ENT=5 GI=19
TNAA was reduced by more than 5 days for all 3 specialty clinics.
Activities • Monthly provider mailings • Analysis by medical group and clinic site
Red
• Quarterly Reports
Red
• Quarterly check-in call with participants • Financial incentive for reaching target
• Implement access to care improvement strategy customized for Clinical Practice Group
Overall Composite 55.7% (86th Percentile)
• Enhance and standardize processes to improve staff competency and proactivity
Overall satisfaction with the Provider Relations department 74.8% for January 2014 survey
Question 8A 60.2% (63rd Percentile)
• Continue to develop existing Provider Relations ACD toolkit to answer questions in common topics authoritatively and completely
Question 8A 58.7% (93rd Met goal in one of three Percentile) measures
• Initial basic customer service training with refreshers and “secret shopper” evaluation for PR staff
Statistically significant improvement from 2014
• Use ACD and email patterns to dedicate more PR staff at times when providers are actually reaching out to us • Secure more provider subscriptions to our monthly newsletter, used to proactively disseminate changes to Medi-Cal programs and other relevant info.
55
Green
• Identify site for implementation
Observe statistically significant improvements upon prior year, or 90th national percentile, in each of three measures on Provider Satisfaction Survey
Question 8A: (Satisfaction with) Provider Relations representative's ability to answer questions and resolve problems. - 80.7% for January 2014 survey Question 8C: (Satisfaction with) Quality of written communications, policy bulletins, and manuals. - 75.8% for January 2014 survey
Status
Yellow
Green
Red
Utilization Management
A. UM Timeliness of Decision and Notification
Ensure 90% of all prior authorization and concurrent review decisions are made within specified turnaround times
B.
Care Coordinator Utilization Management File Audits
Deploy a tool and maintain a schedule to audit care coordinator auth-related activity within core UM system to improve authorization data quality to enhance reporting and trending analysis.
No baseline, 2015 first year of measurement
100%
New coordinator audit developmed and will be implemented Q4
C.
Delegation of UM Activities
Ensure that BTP, HIL, NEMS and CCHCA medical groups are providing 100% of delegated utilization management functions outlined in the 2015 R3 agreements
BTP 2014 UM audit Score: 96% CCHCA 2014 UM audit score: 94% Hill 2014 UM audit score: 100%
100%
On track for CY 2015 schedule
D.
E.
F.
Care Coordination and Services
Expedited - 92% Routine - 99% Retro - 99% Concurrent Review 94%
All categories of TAT were above 90% target. Concurrent Review improved from Q2 average of 92% to 94%. Expedited PA improved 1%, routine improved 3%, and retro improved 5%. Improvement across TAT are the result of reprioritization of authorization activities such as the deimplementation of IP-IP repatriations and removal of medical necessity reviews for services that are rarely denied and largely approved.
A.
Nurse Advice Line
UM Overutilization and Underutilization
Pharmacy Prior Authorization Turnaround time
CareSupport Client Engagement
2013: 90%
• Monthly TAT reports to identify delays in SFHP auth processing and medical necessity reviews • Yearly review of authorization workflow to identify non-value added processes and streamline, where possible
Green
• Five cases per care coordinator, quarterly
Improve Nurse Advice Line to link clinical guidelines to level of Enhanced reporting care disposition
Identify patterns of under or overutilization to create actionable steps to promote medically appropriate utilization NA of services
100%
90%
New report suite and quality reports developed
Applying to existing data trends
• Annual cumulative score
•
Annual Delegation Oversight UM Audit
Green
Green
• Build report specifications with Nurse Advice Line to add clinical guideline dimension • Review enhanced report and identify if specific diagnosis are being triaged as ED level of care or if inappropriately not dispositioned to ED level of care.
Green
• Establish overutilization/underutilization review process • Establish utilization benchmarks for comparison
Green
• Development an action plans to remediate deviations from utilization benchmarks
Provide a decision to pharmacy prior authorization requests in No baseline (interpretation of guidance was 24 hours or one business day updated with 2014 CAP)
Increase the percentage of members referred to CareSupport 74% in 2014 that are “engaged” to 85%
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99%
Over 99% compliance, within our 24 hr PA TAT • Pharmacy and PBM reengineered process to requirement for the managed more condensed TAT months of July and August.
56%
Over the last quarter we have assigned a number of new member many who are in Outreach still.
• Quarterly monitoring
Green
Red
QI Committee Activities and Delegation Oversight
A
Review of Policies and Procedures
B.
Quality Improvement Committee
C.
Pharmacy and Therapeutics Committee
D.
Provider Advisory, Peer Review, and Credentialing Committee
E.
% of encounter data that match medical records
Ensure that 100% of SFHP clinical policies and procedures are up to date, in alignment with contractual, statutory, and No baseline available regulatory requirements, and applicable NCQA standards
Ensure Quality Improvement Committee (QIC) oversight of QI activities outlined in the QI Plan in the six QIC meetings held in NA 2015 Ensure oversight and management of the SFHP formulary is NA conducted in the 4 annual meetings Ensure oversight of credentialing and peer review by the Provider Advisory Committee is conducted in the 6 annual NA meetings
Set baseline for Data Quality per DHCS Data Quality requirements
No baseline
Status Code Green On track to meet target Yellow In danger of not meeting target Red Likely will not meet target
57
100%
All clinical P&Ps updated prior to expiration and reviewed against contractual, statutory, regulatory, and NCQA requirements.
100%
• Timely approval of policies and procedures by QIC and PCC
Green
Meeting held on 08/13/15
• Six meetings to be held in 2015
Green
100%
Meeting held on 07/15/15
• Quarterly and ad hoc P&T Committee meetings
Green
100%
Meeting held on 08/13/15
• Six meetings to be held in 2015
Green
PIP network average compliance rate of 46%.
Enhanced audit methodology for 2016 program year to increase accuracy and help providers identify issues.
• Audit primary care medical records consistency with encounter data
Green
Date:
th
September 24 , 2015
To
SFHP Quality Improvement Committee
From
Jim Glauber, MD, MPH, Chief Medical Officer Anna Jaffe, Director of Health Improvement Adam Sharma, Manager of Practice Improvement
Regarding
SFHP HP-CAHPS Results
Health Plan Consumer Assessment of Healthcare Providers and Systems (HP-CAHPS) is a standardized survey measuring members experience with the health plan and covered health care services. SFHP HP-CAHPS results have consistently been low-performing. As of 2015, SFHP has committed the resources to complete an annual HP-CAHPS survey. This will provide SFHP and the SFHP network with enhanced information about member experience. The HP-CAHPS domains within the survey specifically impacted by the Provider network include Access to Care, Shared Decision-Making, and Provider Communication. For 2015, SFHP is emphasizing improving member access to care as a key organizational and Department of Health Care Services priority. HP-CAHPS results place SFHP in the NCQA Adult Medicaid 10th percentile in access to care member satisfaction. As a result, the Practice Improvement Program (PIP), SFHP’s pay for performance program, has been redesigned to emphasize improvement in measured access and members’ access experience. SFHP also offers a number of technical assistance programs, recognizing the importance of network collaboration on the access improvement endeavor. Below is a summary of SFHP’s Performance. Composite Rating of Health Plan Rating of Personal Doctor Rating of Specialist Seen Most Often Rating of All Health Care Getting Needed Care Getting Care Quickly Customer Service
Score 64.16% 75.54% 73.44% 64.75% 61.96% 66.02% 74.36%
NCQA Adult Medicaid 90th Percentile 81.49% 83.10% 85.31% 76.95% 85.59% 85.52% 90.28%
SFHP Percentile Below 10th Below 25th Below 10th Below 25th Below 10th Below 10th Below 10th
Key Driver Analysis: Based on a key driver analysis of SFHP’s our vendors, the biggest opportunities for improvement are:
Member access to appointments, tests, treatment, and urgent care. Plan’s written materials and information accessed on the Internet to provide members with the information they need. Member’s customer service experience.
Resources for Improvement: In order to support SFHP’s network in improving HP-CAHPS results, SFHP is providing the following resources to the network: 1. Online resources for Improving Member Access to Care: a. Same Day Appointment Scheduling b. Implement Process Improvements to Streamline Patient Flow c. Seek and Implement Best Practices in Urgent Care 2. Trainings on Access Improvement: SFHP will be offering a two-part workshop to teach participants bestpractices in access improvement. This workshop will be offered in November, 2015 & February, 2016. 3. Quality Improvement Collaborative: SFHP’s Health Improvement department will be offering a Quality Improvement Collaborative in the spring of 2016. This collaborative will teach participants QI skills and coach clinics in improving a PIP measure of their choosing. 4. Customized access improvement plans: SFHP is partnering with two provider groups that serve the largest number of our members to create access improvement strategies focused on teaching and implementing best practices in access, creating access dashboards for monitoring of access data, and incorporating the member’s voice into improvement work.
58
Provider Group Performance for Access Composites:
*Provider group performance reflects adjusted data based on member demographics. SFHP’s NCQA score will not be adjusted. **These groups have fewer than 30 reported responses for one of the two questions, which is not an adequate sample size to draw conclusions about the entire population
59
*Provider group performance reflects adjusted data based on member demographics. SFHP’s NCQA score will not be adjusted. **These groups have fewer than 30 reported responses for one of the two questions, which is not an adequate sample size to draw conclusions about the entire population
60
P.O. Box 194247 San Francisco, CA 94119 1(415) 547-7800 1(415) 547-7821 FAX www.sfhp.org
Date:
September 30, 2015
To
Quality Improvement Committee
From
Nicole A. Ylagan – Grievance Analyst
Regarding
Q2 2015 Grievance Report
A total of 147 grievances were reported in the second quarter of 2015 (from April 1-July 30). The same number of grievances, (147) was reported in the first quarter of 2015 (January 1-March 30, 2015). Seven out of 147 grievances in the second quarter were not closed in required 30 day timeframe, as mandated by the Department of Health Care (DMHC) and Department of Health Care Services (DHCS). These grievances were not closed within the 30 day timeframe because of a new SFHP internal process (Grievance Review Committee) that ensures all components of the grievance have been resolved appropriately and have been discussed by the weekly grievance committee.
6279X
61
0515
62
Grievances filed by members who are Seniors and Persons with Disabilities (SPD) There were 68 grievances filed by members who are SPDs in Q2 2015. This number of grievances filed by SPDs increased by 15% compared to the first quarter of 2015.
63
Grievance Categories: Each grievance is divided into nine categories. In this quarter, the top three categories identified were denials, quality of service and quality of care.
64
65
Grievances by Medical Group:
66
Access Grievances: There were nine grievances associated with access. Four grievances were associated with clinics, three with specialty care and two with primary care. In three grievances, members were able to receive earlier appointments within the Timely Access Regulations – 10 business days for a primary care provider and 15 business days for specialty care. By filing a grievance, one member was able to receive an earlier appointment and for the other two grievances, the members were offered appointments within two weeks. • • •
Long wait for an appointment – 7 grievances Unavailable: telephone – 1 grievance Long wait time in the waiting room – 1 grievance
67
UM Appeals Metrics for Q2-2015 UM Appeals Activity: Q2-2015 1
There were a total of 63 medical and pharmacy appeals filed during Q2-2015 out of a quarterly total of 2 3 7,573 authorizations . On a per 1,000 authorizations basis , this is a 6% increase over Q1-2015 (67 4 appeals out of a quarterly total of 8,098 authorizations ). Of the 63 appeals, 42.8% (27 appeals) were denials overturned on appeal, a 28.5% increase over Q12015 (21denials overturned on appeal). A summary of the types of Q2-2015 services appealed is provided in a latter section, Types of Services Handled in UM appeals:
1
Source: 0944ES A&G UM APPEALS REPORT: AUTH RECEIPT DATE: 4/1/2015 - 6/30/2015 as of 7/31/2015. This is an aggregate number of medical and pharmacy appeals and includes Medi-Cal (62 members), Health Workers (1 member). 2 Source: 2015-09-21 PA Operations_v9.23.15 (pharmacy authorizations); Monthly Auths Approved and Denied by Requested Month_9 8 15 (medical authorizations) 3 Q1-2015 = 8.27 appeals/1,000 medical and pharmacy authorizations; Q2-2015 = 8.32 appeals/1,000 medical and pharmacy authorizations 4 Source: 2015-09-21 PA Operations_v9.23.15 (pharmacy authorizations); Monthly Auths Approved and Denied by Requested Month_9 8 15 (medical authorizations)
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UM Out-of-Network Appeals Activity: Q2-2015 There were a total of 5 appeals filed during Q2-2015. There was only 1 OON appeal in Q1-2015. Of the 5 appeals, 2 appeals were overturned, a 200% increase over Q1-2015 (0 appeals). Of the 3 appeals upheld, a 200% increase over Q1-2015 (1 appeal).
69
UM Appeals Activity per 1000 Medical and Pharmacy Authorizations: Q2-2015 In general, the authorization impact of appeals filed in Q2-2015: • Q2-2015: 63 total appeals out of a quarterly total of 7,573 authorizations. • Q1-2015: 67 total appeals out of a quarterly total of 8,098 authorizations. 5
The Q2-2015 UM appeals activity, on a 1,000 authorizations basis , shows a 6% increase over Q1-2015 6 (67 appeals out of a quarterly total of 8,098 authorizations ).
UM Appeals Activity per 1000 Medical and Pharmacy Authorizations: Q1-15 to Q2-15
8.27
5.68
Q1-15 Q2-15
2.59
4.49
3.57 8.32
Appeals Upheld
Appeals Overturned
5
Total Appeals
Q1-2015 = 8.27 appeals/1,000 medical and pharmacy authorizations; Q2-2015 = 8.32 appeals/1,000 medical and pharmacy authorizations 6 Source: 2015-09-21 PA Operations_v9.23.15 (pharmacy authorizations); Monthly Auths Approved and Denied by Requested Month_9 8 15 (medical authorizations)
70
UM Appeals Activity by RX and UM Departments: Q2-2015 • •
During Q2-2015, of a total of 63 appeals, 75% involved pharmacy and 25% involved medical management. During Q1-2015, of a total of 67 appeals, 64% involved pharmacy and 35% involved medical management.
Quarterly totals to date, out of total 130 appeals, 68% involved pharmacy (89 appeals) and 31% involved medical management (41 appeals).
71
Types of Services Handled in UM Appeals: Q1-2015 to Q2-2015 Type of Services Q1-15
Appeals Upheld
Appeals Overturned
Acupuncture treatment
DESONIDE 0.05% CREAM
Circumcision
ENBREL 50 MG/ML SYRINGE
Computed tomography scan of the abdomen
Excision of a left cheek mole
Consultation at UCSF and spirometry
Gender Affirmation Surgery Consult with Dr. Marci Bowers
CT colonography
General surgery consult and hemorrhoidectomy at UCSF for a procedure to remove hemorrhoids Group 2 power wheelchair
Inpatient hospital stay at UCSF Medical Center from 2/13/2015 to 2/14/2015 LEXAPRO 10 MG TABLET (brand for ESCITALOPRAM)
Home fusion for pain control
Medication Harvoni
Lyrica
Medication Sovaldi
Marinol 5mg capsules 3 times daily before meals
Medications Sovaldi and Olysio
Medication Flonase for two years
Medications Sovaldi and Ribasphere
Medication Flucinolone 0.01% solution for two years
Medications Sovaldi and Ribavirin
Medication Harvoni
Neuropsychological testing at UCSF
Medications Advair 250-50 Diskus
New power wheelchair
Nicotrol Cartridge Inhaler
Office visit with Dr. Madhulika Varna at UCSF for a second Powered scooter opinion Patient doesn't have hepatitis C genotype 6, which is not Seat attachment an approved indication for this medication [Medication not described in original note]. Power wheelchair Second DME evaluation Prescription Desonide 0.05% cream
Semi rigid penile prosthesis
Purchase of a Pediatric Wheelchair with Accessories, The care received Xpanda Seating/ Feeding System, and accessories RIBAPAK 400-600 MG DOSEPACK and SOVALDI 400MG Vaginoplasty TABLET RIBAVIRIN 200 MG CAPSULE and SOVALDI 400MG TABLET SOVALDI 400MG TABLET and RIBAVIRIN 200 MG CAPSULE Trulicity 1.5MG/0.5ML # 4 Wheel chair repairs from City Wheelchair
Type of Services Q2-15
Appeals Upheld BARACLUDE 0.5 MG TABLET Additional skilled nursing visits Custom functional foot orthotic Harvoni Liver scan (Fibroscan) MRI of the right knee
Frequency
17
Non-specified Hepatitis C medication
5
Occipital Nerve Blocks at UCSF Orthopedic Consultation at UCSF Ribivirin Single-nucleotide polymorphism (SNP) microarray test Sovaldi Sovaldi and Olysio VIREAD 300 MG TABLET
72
Appeals Overturned Entecavir 0.5mg at dose of #30 per 30 days Aclometasone DIPR 0.05% ointment Adcirca 20mg tablet Additional 12 weeks of Harvoni Advair Belviq 10mg tablet Consultation for Gender Affirmation Surgery CT scan of the thorax, abdomen, and pelvis Daliresp 500mcg tablets entecavir Harvoni HUMIRA 40 MG/0.8 ML SYRINGE Humira 40mg JANUVIA 100 MG Tablet Palatoplasty to address dysphonia and dysarthria PROTOPIC 0.1% OINTMENT Pulmonary rehabilitation SOVALDI Strabismus surgery Sumatriptan 20mg nasal spray VIREAD 300 MG TABLET Voltaren 1% gel
Frequency
5
2
Analysis Quarterly membership between Q1-2015 and Q2-2015 increased by .42% (new members). During this time there was a 6% increase in appeals. Actions Overturned appeals were discussed in the May and June UM Committees for both medical and pharmacy requests. In May 2015, six medical appeals were overturned. Three of those cases were for noncovered benefits and were overturned after further context was added. The discussion in UM Committee resulted in those services being submitted for the ongoing benefit exception process which potentially could allow the service codes to be covered for all members. The process will be monitored via utilization reports. The remaining three cases were medical necessity decisions and were overturned with the introduction of additional clinical information. One of the cases was for an OOMG diagnostic test and it was identified that care was previously rendered at the OOMG facility and necessitated continuity of care. This discussion resulted in the OOMG criteria being revisited to ensure it is not a barrier to care. There were no overturned pharmacy appeals discussed in May. June 2015 did not have any overturned medical appeals. Eight pharmacy appeals were discussed. All of the pharmacy cases were reconsidered with additional submitted clinical information. Two Harvoni cases were overturned after review using the July 2015 revised DHCS Treatment Policy for Hepatitis C, which will be employed going forward. Other discussion outcomes are to explore Lyrica as a step therapy versus the current prior auth methodology and that certain medications be considered non-cosmetic based on the ordering physicians’ specialty, such as topical creams from dermatologists.
73
Medi-Cal State Fair Hearings: April – June Q2 2015 Summary Total Number of State Fair Hearing Requests Received 8 State Fair Hearings where Member did not previously file a Grievance or Appeal with SFHP 4 Medical Group Assignment CHN: 2 HILL: 1 NEMS: 1 UCSF: 2 Kaiser: 1 N/A: 1 Number of State Fair Hearings filed by Special Populations (SPDs, Expansion, OTLIC) 4 SPDs 3 Expansion Trends Total Number of State Fair Hearings where original SFHP action was overturned by 2 Administrative Law Judge (ALJ) or SFHP
Q1 2015 State Fair Hearings by Complaint Type and Resolution UM – Medically Necessary
Appeals Pharmacy – UM – Benefit Medically Coverage Necessary
Pharmacy – Benefit Coverage
ALJ Overturned SFHP’s Action ALJ Upheld SFHP’s 1 (Gym Action membership) Hearing 1 (Strabismus Withdrawn due to 1 (Voltaren Gel) surgery) SFHP Overturn Member NonAppearance Hearing 1 (Fibromyalgia 1 (Hearing Withdrawn by pain meds) aid) Member – Other Reason 6 Issue Outside of Scope 7 Pending 8 TOTAL 1 2 2 Above Bold Line = Adjudicated by Administrative Law Judge after a hearing was held
74
Provider
1
Grievances Plan Timely Reimburseme Administrati Access to nt 4 2 3 on Services
Unknown 5
1 (Kaiser Assignment)
1 (Labs) 1 (Ambulance services) 3 Below Bold Line = No hearing took place or has taken place
1
Provider Grievances are complaints about a particular provider’s behavior towards a member. Plan Administration Grievances are complaints about Customer Service, complaints about SFHP’s policies and procedures, or allegations that SFHP did not follow its policies and procedures. 3 Timely Access to Services Grievances are complaints about inability to schedule an appointment or otherwise see a provider. 4 Reimbursement Grievances are requests for SFHP to pay for a service that has already been rendered. 5 “Unknown” indicates where a member’s complaint was unclear and/or SFHP was unable to contact the member to get clarification about the complaint. 6 “Withdrawn by Member – Other Reason” refers to all situations where a member’s complaint is resolved in a way other than a SFHP overturn of a prior denial. For example, a member’s complaint can be due to a misunderstanding by the member. The complaint is resolved when the member accepts SFHP’s or the ALJ’s explanation of the issue. 7 “Issue Outside of Scope” refers to situations where a case is redirected to the County because a service is carved out of Medi-Cal managed care or when a member was not an eligible SFHP Medi-Cal member at the time of service. 8 “Pending” indicates where a hearing has not yet taken place or a final decision from an ALJ is pending. 2
75
DMHC Independent Medical Reviews (IMR) and Consumer Complaints (CC): April – June Q2 2015 Summary Total IMRs and CCs Received 7 (5 IMRs, 2 CCs) IMRs and CCs where Member did not previously file a Grievance or Appeal with SFHP 4 Line of Business (Special Populations) Medi-Cal: 7 (4 SPDs) Healthy Kids: 0 Healthy Workers: 0 Medical Group Assignment CHN: 4 CCHCA: 1 BTP: 1 N/A: 1 Trends Hepatitis C Medication: 2 Timely Access: 1 Number of CCs and IMRs where original SFHP decision was overturned by DMHC or SFHP 2
Q1 2015 IMRs and CCs by Complaint Type and Resolution IMRs UM Appeal – Pharmacy Medically Appeal – Necessary Medically Necessary
UM Appeal – Benefit Coverage
DMHC Overturned 1 (Hep C) SFHP Action DMHC Upheld SFHP 1 (Ambien/ Action Klonopin) DMHC Neutral Resolution6 RTP SFHP 1 (Daliresp) Overturned RTP SFHP Upheld 1 (Hep C) RTP Neutral Resolution7 Issue Outside of 1 (Anthem Scope 8 Blue Cross) Pending 9 TOTAL 1 4 Above Bold Line = Adjudicated by DMHC or IMR Organization
Pharmacy Appeal – Benefit Coverage
Grievance – Provider 1
Consumer Complaints Grievance – Grievance Plan – Eligibility 3 Administration 2
1 (Covered CA)
Grievance – Reimburse ment 4
Grievance – Timely Access to Services 5
1 (Colonoscopy)
1 1 Below Bold Line = Return to Plan (RTP) and adjudicated by SFHP grievance/appeal process
76
1
Provider Grievances are complaints about a particular provider’s behavior towards a member. Plan Administration Grievances are complaints about Customer Service, complaints about SFHP’s policies and procedures, or allegations that SFHP did not follow its policies and procedures. 3 Eligibility Grievances are CCs regarding a member’s SFHP eligibility or termination from an SFHP benefit plan. 4 Reimbursement Grievances are requests for SFHP to pay for a service. 5 Timely Access to Services Grievances are complaints about inability to schedule an appointment or otherwise see a provider. 6 A “DMHC Neutral Resolution” occurs when DMHC adjudicates the case but is unable to find that an SFHP action was non-compliance. 7 A “RTP Neutral Resolution” occurs when a IMR or CC is returned to SFHP for processing as a grievance and neither side of a conflict can be verified. Instead a solution is implemented that resolves the member’s complaint. For example, if a member has a disagreement with a provider, a neutral solution can be to allow the member to transfer to another provider. 8 “Issue Outside of Scope” refers to situations where a case is outside of DMHC’s jurisdiction or outside of SFHP’s scope. These include Medi-Cal eligibility cases, Medicare cases and cases that should be redirected to a different agency/health plan. 9 “Pending” indicates where a closing letter has not been issued by DMHC yet. 2
77
Date:
October 8th, 2015
To
SFHP Quality Improvement Committee
From
Sean Dongre Supervisor, Provider Relations
Regarding
Provider Satisfaction Survey
In early 2015, SPH Analytics contacted San Francisco Health Plan’s providers on our behalf to conduct this year’s Provider Satisfaction Survey. This survey targeted primary care and high-volume specialty care providers, and administrative staff, to measure their satisfaction with San Francisco Health Plan. Providers were asked to rate their satisfaction with SFHP as compared to other health plans with which they participate. The survey was amended to support NCQA Standards for Health Plan Accreditation and included questions that meet the California DMHC Timely Access requirements. The same survey was used for the 2012 and 2013 survey, giving us the opportunity to compare providers’ responses to the previous years, as well as to SPH Analytics’ health plan clients nationwide. A total of 125 surveys were completed for a 14% response rate to mail/Internet surveys and 13% response rate to phone surveys. These response rates are in line with SPH Analytics’ other health plan clients. Results: In general, providers’ highest satisfaction scores are for member incentive programs and whether providers believe they help patients’ health care behaviors. SFHP is a strong performer in overall satisfaction and particularly for its Utilization Management, Network/Coordination of Care, and Provider Relations functions. Overall satisfaction compared with all other plans went up from 36.4% satisfied to 47.1% satisfied, which is good for 80th percentile among SPH Analytics’ Medicaid clients. Among individual functions, Utilization Management and Care Support are at 75th Medicaid percentile, and Provider Relations is at 86th percentile. Last year’s weak points, in Pharmacy and Formulary, have improved across the board in the first full year under our new Pharmacy Benefits Manager. We have implemented several procedural and formulary changes, including a Medication Therapy Management program and new authorization forms. However, compared with the previous year, providers are significantly less satisfied overall with Provider Relations and Customer Service. The process of obtaining member information (eligibility, benefits, etc) is the source of greatest provider dissatisfaction at < 10th percentile. SFHP’s secure provider portal, which is a major source of eligibility information, has been troubled with several technical difficulties this year and we are evaluating options for replacement and repair. Please see the included Executive Summary for details about methodology and results.
78
Enclosures: Survey Executive Summary Survey Highlights Year-to-Year and National Comparisons Custom questions on SFHP’s member incentive programs Respondent Demographics
79
1. Executive Summary SPH Analytics (SPH ANALYTICS), a National Committee for Quality Assurance (NCQA) Certified Survey Vendor, was selected by San Francisco Health Plan to conduct its 2015 Provider Satisfaction Survey. Information obtained from these surveys allows plans to measure how well they are meeting their providers’ expectations and needs. Based on the data collected, this report summarizes the results and assists in identifying plan strengths and opportunities. SPH ANALYTICS followed a two-wave email blast and a one-wave mail with phone follow-up survey methodology to administer the Provider Satisfaction Survey from January to March 2014. A total of 125 surveys were completed (56 mail, 40 Internet, and 29 phone), yielding a response rate of 13.7% for the mail/Internet data component and 12.6% for the phone data component. Please refer to the Methodology (Section 2) for further detail on the calculation of response rates. The chart below presents 2015 Summary Rates1 for San Francisco Health Plan’s composites and key attributes. Data and significance testing for trend years and the 2014 SPH ANALYTICS Medicaid Book of Business are also provided for comparison. 2014 SPH ANALYTI CS Medicaid BoB Summary Rates2
2015 Summary Rates
2012 Summary Rates
Overall Satisfaction with San Francisco Health Plan
69.6%
69.8%
69.8%
All Other Plans (Comparative Rating)
47.1%
45.2%
36.4%
Finance Issues
33.9%
35.8%
31.5%
Utilization Management and Care Support
43.7%
48.3%
34.5%
Network/Coordination of Care
44.3%
40.1%
29.7%
Pharmacy
25.4%
25.7%
22.1%
Health Plan Customer Service Staff
31.7%
52.0%
41.5%
Provider Relations
55.7%
74.8%
41.6%
Recommend to Other Physicians' Practices
81.6%
81.7%
83.3%
Composites/Attributes
*
**
*Indicates a significant difference when compared to previous years. **Indicates a significant difference when compared to the 2014 SPH ANALYTICS Medicaid Book of Business.
The Summary Rate represents the most favorable response percentage(s). SPH Analytics’ 2014 Medicaid Book of Business consists of data from 23 plans representing 12,193 respondents in Primary Care, Specialty, and Behavioral Health areas of medicine.
1 2
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Provider Satisfaction Report Highlights
San Francisco Health Plan 2015
Highest and Lowest Performing Questions Summary Rate Scores
2014 SPH Analytics B.o.B.***
2015 Mean Scores**
n*
SRS*
San Francisco
SPH Analytics B.o.B.
Medicaid
Aggregate
5C. Your patients' access to non-urgent primary care.
103
84.5%
2.98
NA
NA
NA
10D. Diabetes Care gift card.
77
83.1%
4.13
NA
NA
NA
10B. Childhood immunization gift card.
78
82.1%
4.18
NA
NA
NA
6A. Extent to which formulary reflects current standards of care.
103
27.2%
3.14
3.15
23.1%
24.9%
6B. Variety of drugs on the formulary.
104
24.0%
3.02
3.00
19.7%
22.3%
6D. Availability of alternative drugs to substitute for those not included in the formulary.
101
19.8%
2.85
3.07
21.1%
22.2%
Highest Scoring Questions
Lowest Scoring Questions
Ratings of Overall Satisfaction
Highest Performing Composite
Overall Satisfaction
Provider Relations
90%
70%
80%
60%
60.2%
58.7%
69.6%
70%
48.1%
50%
60%
40%
50%
30%
40% 20%
30% 10% 20%
0% 10%
8A. Provider Relations 8B. Quality of provider representative's ability to orientation process. answer questions and resolve problems.
0%
San Francisco Health Plan
Priority Matrix Composite
Correlation****
Loyalty Analysis Percentile
San Francisco Health Plan
Strength Provider Relations
Defection 1.8%
0.515
8C. Quality of written communications, policy bulletins, and manuals.
86th
Loyal 21.4%
Top Priority No composites are considered Top Priority Strength: Composite is highly correlated with overall satisfaction and ranks at or above the 75th percentile when compared to the SPH Analytics Book of Business benchmark. Top Priority: Composite is highly correlated with overall satisfaction and ranks below the 75th percentile when compared to the SPH Analytics Book of Business benchmark.
Indifferent 76.8% A loyal provider is completely satisfied with the plan and would recommend the plan to other physicians' practices. A provider in the defection zone is completely dissatisfied with the plan and would not recommend the plan to other physicians' practices. All other providers are considered indifferent.
* The Valid n represents the number of responses to the question. Summary Rate Scores (SRS) represent the top two response percentages ("Well above average" and "Somewhat above average;" "Very Satisfied" and "Satisfied;" "Completely satisfied" and "Somewhat satisfied;" "Yes;" and "Strongly Agree" and "Agree"). ** Mean scores are the average of all responses. SPH Analytics B.o.B. is represented by the Medicaid Book of Business. *** SPH Analytics's 2014 Medicaid Book of Business benchmark consists of data from 23 plans representing 12193 respondents, while the Aggregate Book of Business benchmark consists of data from 33 plans representing 14423 respondents in Primary Care, Specialty, and Behavioral Health areas of medicine. **** A correlation coefficient approaching a value of +/- 1.000 represents an increasing association of the composite with overall satisfaction. Note: Significance Testing - Cells highlighted in red denote current year plan percentage is significantly lower when compared to trend or benchmark data; cells highlighted in green denote current year plan percentage is significantly higher when compared to trend or benchmark data; no shading denotes that there was no significant difference between the percentages, there is no comparable data, or that there was insufficient sample size to conduct the statistical test. All significance testing is performed at the 95% significance level.
SPH Analytics
81
1
Summary of Trend/Benchmark Comparisons
San Francisco Health Plan
Composites and Attributes - Summary Rate Scores
Provider Satisfaction Survey Current
125 Total Respondents
2015
2014
Composites and Key Questions Valid n
Summary Valid n Rate*
2014 SPH Analytics Book of Business Benchmarks**
Summary Rate*
Medicaid
Aggregate
Overall Satisfaction
115
69.6%
106
69.8%
69.8%
71.3%
11A. Would you recommend SFHP to other physicians' practices?
114
81.6%
109
81.7%
83.3%
85.0%
11B. Please rate your overall satisfaction with San Francisco Health Plan.
115
69.6%
106
69.8%
69.8%
71.3%
All Other Plans (Comparative Rating)
121
47.1%
124
45.2%
36.4%
37.8%
1A. How would you rate SFHP compared to all other health plans you contract with?
121
47.1%
124
45.2%
36.4%
37.8%
Finance Issues
79
33.9%
79
35.8%
31.5%
33.8%
2A. Consistency of reimbursement fees according to your contract rates.
77
33.8%
78
30.8%
27.7%
31.1%
2B. Accuracy of claims processing.
79
35.4%
79
36.7%
34.0%
36.3%
2C. Timeliness of claims processing.
75
32.0%
78
37.2%
34.6%
36.3%
2D. Resolution of claims payment problems or disputes.
70
34.3%
78
38.5%
29.7%
31.5%
Utilization Management and Care Support
117
43.7%
111
48.3%
34.5%
35.7%
3A. Access to knowledgeable UM staff.
99
37.4%
102
46.1%
31.8%
33.4%
3B. Procedures for obtaining pre-certification/referral/authorization information.
113
39.8%
109
44.0%
33.3%
34.7%
3C. Timeliness of obtaining pre-certification/referral/authorization information.
117
41.0%
111
43.2%
33.3%
34.3%
3D. The health plan's facilitation/support of appropriate clinical care for patients.
111
43.2%
105
50.5%
32.4%
34.0%
3E. Degree to which the plan covers and encourages preventive care and wellness.
112
57.1%
104
57.7%
41.9%
42.2%
Network/Coordination of Care
113
44.3%
108
40.1%
29.7%
32.7%
4A. The number of specialists in this health plan's provider network.
113
40.7%
108
32.4%
27.0%
29.7%
4B. The quality of specialists in this health plan's provider network.
110
54.5%
105
49.5%
34.7%
37.6%
4C. The timeliness of feedback/reports from Specialists in this health plan's provider network.
109
37.6%
107
38.3%
27.5%
30.8%
Pharmacy
104
25.4%
100
25.7%
22.1%
23.7%
6A. Extent to which formulary reflects current standards of care.
103
27.2%
99
25.3%
23.1%
24.9%
6B. Variety of drugs on the formulary.
104
24.0%
97
23.7%
19.7%
22.3%
6C. Ease of prescribing your preferred medications within formulary guidelines.
104
30.8%
100
30.0%
24.3%
25.2%
6D. Availability of alternative drugs to substitute for those not included in the formulary.
101
19.8%
100
24.0%
21.1%
22.2%
Health Plan Customer Service Staff
90
31.7%
95
52.0%
41.5%
43.3%
7A. Ease of reaching health plan customer service staff over the phone.
90
30.0%
92
54.3%
39.3%
41.6%
7B. Process of obtaining member information (eligibility, benefit coverage, co-pay amounts).
85
29.4%
88
50.0%
44.1%
45.0%
7C. Overall satisfaction with Customer Services.
90
35.6%
95
51.6%
41.0%
43.2%
Provider Relations
92
55.7%
99
74.8%
41.6%
41.5%
8A. Provider Relations representative's ability to answer questions and resolve problems.
88
60.2%
88
80.7%
54.2%
53.9%
8B. Quality of provider orientation process.
77
48.1%
78
67.9%
34.0%
34.4%
8C. Quality of written communications, policy bulletins, and manuals.
92
58.7%
99
75.8%
36.5%
36.3%
* Summary Rates represent the most favorable response percentage(s). ** SPH Analytics's 2014 Medicaid Book of Business consists of data from 23 plans representing 12193 respondents, while the Aggregate Book of Business consists of data from 33 plans representing 14423 respondents in Primary Care, Specialty, and Behavioral Health areas of medicine. See Technical Notes for more information. Note 1: Significance Testing - Cells highlighted in red denote current year plan percentage is significantly lower when compared to trend or benchmark data; Cells highlighted in green denote current year plan percentage is significantly higher when compared to trend or benchmark data; No shading denotes that there was no significant difference between the percentages, there is no benchmark, or that there was insufficient sample size to conduct the statistical test. All significance testing is performed at the 95% significance level. Note 2: Question wording for Q2A, Q6B, Q6D, Q7A, and Q7C on the SFHP 2013 survey tool is different than the 2013 SPH Analytics Book of Business. Caution is advised when making comparisons. See Question Summaries for further detail. Note 3: The Overall Satisfaction Summary Rate includes only 11B. It does not include 11A "Would you recommend SFHP to other physicians' practices?" Note 4: Caution is advised when comparing the Provider Relations composite and attributes to the 2013 SPH Analytics Book of Business. Attributes in the Book of Business were gated by the following question: "Do you have a Provider relations representative from this health plan assigned to your practice?" The 2013 SFHP survey tool does not include this gate question. Additionally, the response option scale differs from the 2013 SPH Analytics Book of Business. See Question Summaries for further detail.
SPH Analytics
82
3A
Benchmark Comparisons
San Francisco Health Plan
2014 SPH Analytics Medicaid Book of Business Percentiles
Provider Satisfaction Survey
125 Total Respondents Composite/Attribute
2015 San Francisco Summary Rate Score*
Percentile Ranking
2014 SPH Analytics B.o.B. Summary Rate**
2014 SPH Analytics Medicaid B.o.B. Percentiles 25th
50th
75th
90th
Overall Satisfaction
69.6%
54th
69.8%
62.0%
69.2%
76.4%
79.8%
11A. Would you recommend SFHP to other physicians' practices?
81.6%
50th
83.3%
79.5%
81.6%
89.2%
92.0%
11B. Please rate your overall satisfaction with San Francisco Health Plan.
69.6%
54th
69.8%
62.0%
69.2%
76.4%
79.8%
All Other Plans (Comparative Rating)
47.1%
